HospitalInspections.org

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Based on interview, record review, and review of the hospital policies and procedures, the hospital failed to provide medical screening examination for a patient following a change in condition, failed to ensure qualified professionals approved by the Governing Body provide medical screening examinations; failed to provide necessary stabilizing treatment for an emergency medical condition; and, failed to implement policies and procedures related to completion of the "Authorization to Transfer" form for patients transferred from the Emergency Department to other acute care facilities in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to comply with EMTALA regulations risks poor patient outcomes, injury and death.

Findings included:

The hospital failed to provide medical screening examination reassessment for a patient whose condition changed prior to leaving the hospital premesis.

The hospital By-Laws did not include obstetrical nurses as medical professionals permitted to provide medical screening examinations.

Cross-reference A2406

A patient in the hospital lobby refused to leave the hospital. The local police department was called. The officer felt the patient was a danger to themselves, involked the Involuntary Treatment Act, and was taken to a different hospital emergency department.

Cross-reference A2407

Missing or incomplete "Authorization to Transfer" documents in 4 of 8 medical records of transferred patients.

Cross-reference A 2409

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Based on interview, document review and medical record review, the hospital staff failed to 1) reassess a patient when the patient had a change in condition prior to leaving the hospital for 1 of 22 Emergency Department patient records reviewed and 2) ensure that individuals entering the building seeking medical assistance were initially screened by qualified staff, and failed to specify in hospital regulations or by-laws which medically qualified personnel had been determined qualified to conduct medical screening examinations (MSEs).

Failure to ensure patients receive a comprehensive medical screening examination and reassessment when they have a change in condition by qualified medical professional puts patients at risk for poor health outcomes, injury or death.

Findings included:

Item #1 Failure to reassess following a change in condition

1. Document review of the hospital policy titled, "Emergency Patients, Screening and Mental Health Patient Transfer (EMTALA)," #13472 dated 11/21/19, showed that persons who develop or are found to have a potential emergency medical condition while in any department or hospital owned clinic will be provided with appropriate immediate assistance and transfer to the nearest Emergency Department. The hospital will provide care until the emergency medical condition ceases to be an emergency or until the individual is properly transferred to another facility. A physician at the receiving facility must agree to accept the patient in transfer prior to sending the patient. An "Authorization to Transfer" form must be completed for every emergency patient. All sections of the form must be completed with particular attention paid to documentation of patient condition, reason for transfer, accepting facility and name of accepting provider, what documentation was sent with the patient, risks and benefits of transfer and mode of transport. For Psychiatric Emergencies and Transfers, a mental health professional will be available at all times to provide a mental health screening for ED patients who have conditions that may indicate a psychiatric emergency condition. In addition to the mental health screening exam, a complete Medical Screening Exam (MSE) will be performed and documented. "Stabilization" of a psychiatric patient requires that the patient be "protected" from committing harm to self or others. Stabilization may include the use of either medication or physical restraints. Any patient whose psychiatric condition requires transfer to another facility must have an "Authorization to Transfer" form completed.

2. During an interview with the investigator on 11/29/21 at 9:30 AM, the ED Physician Assistant (PA) (Staff #13) stated that a patient (Patient #1) arrived in the ED from Smokey Point Behavioral Health (SPBH). The PA called SPBH to see what thier goals were for sending the patient to Cascade Valley Hospital (CVH) ED. The patient was sent over because of inappropriate behavior and there was some concern about possible seizures during withdrawal from fentanyl. The patient was voluntary at SPBH and had been admitted there the day before for detoxification from drug abuse. The patient was complaining of pain 10 out of 10 and wanted pain medication. The PA explained that there would be no narcotics given in the ED. The patient would occasionally yell out and be frustrated. The patient agreed to take orally, Ativan, Benedryl and Haldol. The patient's symptoms improved. The PA contacted SPBH to send the patient back,,but was told the doctor would not accept the patient. The PA told the patient that SPBH was not an option and that she could have a full medical screening with laboratory tests and electrocardiogram, then wait for an available bed at another facility. The patient did not want to have the testing and asked to be discharged. The patient was alert and oriented, not suicidal or homicidal and had no hallucinations. The patient was discharged.

3. During an interview with the investigator on 11/24/21 at 5:00 PM, a hospital security guard (Staff #11) stated that he had observed (Patient #1) in the ED yelling at staff, complaining, being argumentative and sexually inappropriate. The security guard observed the patient in the lobby after discharge. The patient appeared confused. The patient was seen falling onto another person who was sitting in the lobby. The patient was wandering in the lobby, making other people uncomfortable. The guard obtained a bus pass for the patient and helped them out to the bus stop, explaining the bus schedule. The patient walked out into the street where traffic was passing. The security guard escorted the patient back to the lobby. The security guard called the police to remove the patient from the premises. The security guard saw the patient leave the lobby and get into a car's passenger seat. The guard told the patient to get out of the car. The patient got out of the car when the police officer told her to get out and the police officer escorted the patient back into the lobby. The police called for an ambulance and told the security guard that the patient was going to Providence Everett Hospital.

4. Review of a document titled, "Security Daily Activity Report," dated 11/03/21 showed that the security guard was called to the ED at 3:29 PM to stand by outside a patient room. The patient (Patient #1) was cursing and yelling obscenities and performing inappropriate sexual actions. The patient was hitting the bed repeatedly and the guard attempted to deescalate the situation. The patient lashed out and cursed at the guard, so the guard moved out of line of sight of the patient. At 4:22 PM the patient appeared calm, and the ED staff ended the stand by. At 5:28 PM the guard received a call about a disturbance in the lobby from registration. Patient #1 was wandering around the lobby. The patient was redirected to a chair in the lobby. At 6:05 PM the security guard went to assist Patient #1 who had been discharged and was being disorderly. The guard contacted the House Supervisor (Staff #10) requesting a bus pass for the patient and 2 bus passes were obtained. The guard walked the patient with her luggage and personal belongings out to the bus stop and guided her to ensure she did not fall over. The patient ripped up the bus passes and stumbled into the street as there were vehicles speeding by. At 6:40 PM the patient was in the lobby and was referring to people who were not in the room and pointing at chairs stating a family member was there. The patient appeared confused and disoriented and almost fell over several times and did not seem to be aware of her position in relation to furniture. At 7:15 PM the patient was observed to fall over an older female sitting in the lobby. When the guard asked Patient #1 if she needed anything, and she asked where she could go. The guard instructed the patient to return to the chair by the fireplace in the lobby. At 7:30 PM the House Supervisor and registration staff approached the security guard stating Police needed to be called to remove Patient #1. Police were called. Security guard told the House Supervisor of all of the attempts to assist Patient #1 and that she had walked almost into the road and was almost struck by a vehicle. He also told the House Supervisor that the patient had burned her arm by touching the fireplace glass and was not aware of her environment and position in relation to furniture. At 8:10 PM a police officer arrived, and the security guard described the situation with the patient. The officer contacted ED nursing and attempted to obtain DCR (designated crisis responder) services by contacting the patient's social worker. The police stated the patient was a danger to herself and others. The patient was observed as she left the lobby and walked into the hospital parking lot and opened the passenger rear door and entered the passenger front door. The security guard told the patient to get out. The police officer then told the patient to get out. The patient was talking in circles about their friend's vehicle. The police officer then called for an ambulance so that the patient could be taken (involuntarily) to Providence Hospital.

5. During an interview with the investigator on 11/29/21 at 9:30 AM the ED Physician Assistant (Staff #13) stated that they were aware that the patient was causing a disturbance in the lobby and had torn up the bus pass. They were aware the police asked for contact information and the chart listed the patient's social worker as her contact. Staff #13 stated that the patient was voluntary, and that the patient's symptoms were similar to withdrawal from opiates. The patient told her that this was no different from previous opiate withdrawals. Staff #13 stated that they didn't see anything that would meet "gravely disabled" definition. She didn't see that the patient needed to be involuntary and didn't think DCR was needed. She stated that she did not know that the patient had left the facility until she received a call from a physician at Providence Everett Hospital. She did not know an ambulance had been called.

6. During an interview with the investigator on 11/23/21 at 1:37 PM, the Hospital Supervisor (HS) (Staff #10) stated that they had seen the patient (Patient #1) in the lobby and tried to calm them down. They observed the patient laying on the floor, standing, sitting. The patient would not call for a ride. The patient became less able to be redirected and was escalating. The police were called. The HS stated the police officer was calling Smokey Point Behavioral Health when they left. The patient's behavior waxed and waned, increasing and decreasing agitation. HS said they did not observe the patient burn themself on the fireplace and that it would be difficult to do so because of the safety precautions blocking access to the fireplace. Staff #10 stated he saw no signs of burns or of any pain in the patient's arms. Staff #10 stated that the patient had not been taken back into the ED because they weren't listening and became more resistant. The HS stated that the patient's behavior was the same behavior as she was admitted for at Smokey Point and so they did not think returning the patient to the ED was necessary.

7. During an interview with the investigator on 12/01/21 at 6:29 PM, the police officer (Staff #14) stated that security at the hospital had called dispatch for a discharged patient refusing to leave. When the officer arrived at the hospital, they observed Patient #1 sitting awkwardly then getting up, wandering around. The patient looked out of it. The officer called the patient's social worker and while on the phone he saw the patient get up and walk out to the parking lot trying to get into cars. He went out to the parking lot and told the patient to get out of the car. The patient walked back into the lobby. The patient was bobbing her head around and not really answering questions. She kept looking for her social worker's number. The officer said he took the patient on an ITA (Involuntary Treatment Act). The patient was a danger to herself. He said that the patient had burned her arms on the fireplace when he walked out to his patrol car. The ambulance was already on its way and arrived as the officer walked back into the hospital. EMS addressed the burns. The officer stated that the reason the patient was not taken back into the ED at CVH was because the police were not supposed to take patients there. The police department wants involuntary patients to be sent to Providence Everett as they have more resources. This is for mental health, addiction, and suicidal patients. This policy was verbally communicated to the officers by police leadership. There is no written policy. The officer stated he had called for the ambulance.

Item #2 Qualified Personnel perform MSE

1. During an interview with the investigator on 11/18/21 at 4:07 PM, a Registered Nurse (RN) (Staff #7) working in the Obstetrics Department (OB) stated that pregnant patients that come to the hospital to rule out labor either go directly to the OB department if they have established care with a provider, or if the patient does not have a doctor, they go to the Emergency Department. If the patient is not in labor the provider doesn't usually come in to see them. The nurse calls the provider and gives them report and the providers give an order to discharge the patient and any specific instructions.

2. Review of the hospital policy titled, "OB Triage Management" policy #79252 dated 09/30/20 showed that all patients presenting to the Family Birth Center for evaluation of labor status (labor check) will be assessed by a Registered Nurse skilled in labor management. A qualified triage screener RN must have a minimum of 3 years labor and delivery experience and are at a competent, proficient, or expert level of competency or have 2-3 years labor and delivery experience and have an experienced RN "back up" available. Patients who present to the Family Birth Center for evaluation will receive an initial triage assessment by a qualified RN screener promptly upon arrival. The RN is responsible for completing re-evaluations and re-determining condition levels, as well as notfying provider of patient status.

3. Review of the hospital policy titled, "Admission and Assessment of Labor of Full-Term Gestation Pregnancy-FBC-CVH" policy #14819 dated 11/19/20 showed that for established patients the labor and delivery nurse may assess and determine their status of labor, report to the appropriate provider, and admit or discharge accordingly. For a patient without an established provider, the same evaluation may be done by the RN, but the patient must be seen by a provider prior to discharge.

4. Review of the hospital By-Laws, dated 09/25/20 showed that physicians and mid-level providers are authorized to perform medical screening examinations.
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Based on interview, document review and medical record review, the hospital failed to provide necessary stabilizing treatment for an emergency medical condition that was determined at a later time by care providers at another facility for 1 of 25 records reviewed.

Failure to perform stabilizing treatment for an emergency medical condtion created risk for patient harm.

Findings included:

1. Document review of the hospital policy titled, "Emergency Patients, Screening and Mental Health Patient Transfer (EMTALA)," #13472 dated 11/21/19 showed that persons who develop or are found to have a potential emergency medical condition while in any department or hospital owned clinic will be provided with appropriate immediate assistance and transfer to the nearest Emergency Department. The hospital will provide care until the emergency medical condition ceases to be an emergency or until the individual is properly transferred to another facility. "Stabilization" of a psychiatric patient requires that the patient be "protected" from committing harm to self or others. Stabilization may include the use of either medication or physical restraints.

2. During an interview with the investigator on 11/29/21 at 9:30 AM the ED Physician Assistant (PA) (Staff #13) stated that a patient (Patient #1) arrived in the ED from Smokey Point Behavioral Health (SPBH). The PA called SPBH to see what thier goals were for sending the patient to Cascade Valley Hospital (CVH) ED. The patient was sent over because of inappropriate behavior and there was some concern about possible seizures during withdrawal from fentanyl. The patient was voluntary at SPBH and had been admitted there the day before for detoxification from drug abuse. The patient was complaining of pain 10 out of 10 and wanted pain medication. The PA explained that there would be no narcotics given in the ED. The patient would occasionally yell out and be frustrated. The patient agreed to take orally, Ativan, Benadryl and Haldol. The patient's symptoms improved. The PA contacted SPBH to send the patient back, but was told the doctor would not accept the patient. The PA told the patient that SPBH was not an option and that she could have a full medical screening with laboratory tests and electrocardiogram, then wait for an available bed at another facility. The patient did not want to have the testing and asked to be discharged. The patient was alert and oriented, not suicidal or homicidal and had no hallucinations. The patient was discharged.

3. Review of a document titled, "Security Daily Activity Report" dated 11/03/21, showed that the security guard was called to the ED at 3:29 PM to stand by outside a patient room. The patient (Patient #1) was cursing and yelling obscenities and performing inappropriate sexual actions. The patient was hitting the bed repeatedly and the guard attempted to deescalate the situation. The patient lashed out and cursed at the guard, so the guard moved out of line of sight of the patient. At 4:22 PM the patient appeared calm, and the ED staff ended the stand by. At 5:28 PM the guard received a call about a disturbance in the lobby from registration. Patient #1 was wandering around the lobby. The patient was redirected to a chair in the lobby. At 6:05 PM the security guard went to assist Patient #1 who had been discharged and was being disorderly. The guard contacted the House Supervisor (Staff #10) requesting a bus pass for the patient and 2 bus passes were obtained. The guard walked the patient with her luggage and personal belongings out to the bus stop and guided her to ensure she did not fall over. The patient ripped up the bus passes and stumbled into the street as there were vehicles speeding by. At 6:40 PM the patient was in the lobby and was referring to people who were not in the room and pointing at chairs stating a family member was there. The patient appeared confused and disoriented and almost fell over several times and did not seem to be aware of her position in relation to furniture. At 7:15 PM the patient was observed to fall over an older female sitting in the lobby. When the guard asked Patient #1 if she needed anything, and she asked where she could go. The guard instructed the patient to return to the chair by the fireplace in the lobby. At 7:30 PM the House Supervisor and registration staff approached the security guard stating Police needed to be called to remove Patient #1. Police were called. Security guard told the House Supervisor of all of the attempts to assist Patient #1 and that she had walked almost into the road and was almost struck by a vehicle. He also told the House Supervisor that the patient had burned her arm by touching the fireplace glass and was not aware of her environment and position in relation to furniture. At 8:10 PM a police officer arrived, and the security guard described the situation with the patient. The officer contacted ED nursing to obtain the name and number of the patient's contact listed in the medical record. The patient's social worker was the contact. The police stated the patient was a danger to herself and others. The patient was observed as she left the lobby and walked into the hospital parking lot and opened the passenger rear door and entered the passenger front door. The security guard told the patient to get out. The police officer then told the patient to get out. The patient was talking in circles about their friend's vehicle. The police officer then called for an ambulance so that the patient could be taken involuntarily to Providence Hospital.

4. During an interview with the investigator on 11/23/21 at 1:37 PM the Hospital Supervisor (HS) (Staff #10) stated that they had seen the patient (Patient #1) in the lobby and tried to calm them down. They observed the patient laying on the floor, standing, sitting. The patient would not call for a ride. The patient became less able to be redirected and was escalating. The police were called. The HS stated the police officer was calling Smokey Point Behavioral Health when they left. The patient's behavior waxed and waned, increasing and decreasing agitation. HS said they did not observe the patient burn themself on the fireplace and that it would be difficult to do so because of the safety precautions blocking access to the fireplace. Staff #10 stated he saw no signs of burns or of any pain in the patient's arms. Staff #10 stated that the patient had not been taken back into the ED because they weren't listening and became more resistant. The HS did not call EMS (Emergency Medical Services).

5. . During an interview with the investigator on 11/24/21 at 5:00 PM a hospital security guard (Staff #11) stated that he had observed (Patient #1) in the ED yelling at staff, complaining, being argumentative and sexually inappropriate. The security guard observed the patient in the lobby after discharge. The patient appeared confused. The patient was seen falling onto another person who was sitting in the lobby. The patient was wandering in the lobby, making other people uncomfortable. The guard obtained a bus pass for the patient and helped them out to the bus stop, explaining the bus schedule. The patient walked out into the street where traffic was passing. The security guard escorted the patient back to the lobby. The security guard called the police to remove the patient from the premises. The security guard saw the patient leave the lobby and get into a car's passenger seat. The guard told the patient to get out of the car. The patient got out of the car when the police officer told her to get out and the police officer escorted the patient back into the lobby. The police called for an ambulance and told the security guard that the patient was going to Providence Everett Hospital.

6. During an interview with the investigator on 11/29/21 at 9:30 AM the ED Physician Assistant (Staff #13) stated that they were aware that the patient was causing a disturbance in the lobby and had torn up the bus pass. They were aware the police asked for contact information and the chart listed the patient's social worker as her contact. Staff #13 stated that the patient was voluntary, and that the patient's symptoms were similar to withdrawal from opiates. The patient told her that this was no different from previous opiate withdrawals. Staff #13 stated that they didn't see anything that would meet "gravely disabled" definition. She didn't see that the patient needed to be involuntary and didn't think DCR was needed. She stated that she did not know that the patient had left the facility until she received a call from a physician at Providence.

7. During an interview with the investigator on 12/01/21 at 6:29 PM, the police officer (Staff #14) stated that security at the hospital had called dispatch for a discharged patient refusing to leave. When the officer arrived at the hospital, they observed Patient #1 sitting awkwardly then getting up, wandering around. The patient looked out of it. The officer called the patient's social worker and while on the phone he saw the patient get up and walk out to the parking lot trying to get into cars. He went out to the parking lot and told the patient to get out of the car. The patient walked back into the lobby. The patient was bobbing her head around and not really answering questions. She kept looking for her social worker's number. The officer said he took the patient on an ITA (Involuntary Treatment Act) because the patient was a danger to herself. He said that the patient had burned her arms on the fireplace when he walked out to his patrol car. He did not observe the patient receive the burns. The ambulance was already on its way and arrived as the officer walked back into the hospital. EMS addressed the burns. The officer stated that the reason the patient was not taken back into the ED at CVH was because the police were not supposed to take patients there. The police department wants involuntary patients to be sent to Providence Everett as they have more resources. This is for mental health, addiction, and suicidal patients. This was verbally communicated to the officers by police department leadership.There is no written policy. The officer stated he had called for the ambulance.

8. Medical record review for Patient #1 did not show that the patient had been returned to the Emergency Department for stabilizing treatment prior to transfer to another acute care facility.

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Based on interview, document review and medical record review, the hospital failed to follow hospital policies and procedures related completion of the "Authorization to Transfer" form for patients transferred from the Emergency Department to other acute care hospitals. (Patients #4, #12, #17, #20)

Failure to follow policies and procedures designed to provide clear communication between the patient, provider and receiving facility risks delay in patient care, re-transfer and poor patient outcomes.

Findings included:

1. Document review of the hospital policy titled, "Emergency Patients, Screening and Mental Health Patient Transfer (EMTALA)," #13472 dated 11/21/19, showed that persons who develop or are found to have a potential emergency medical condition while in any department or hospital owned clinic will be provided with appropriate immediate assistance and transfer to the nearest Emergency Department. The hospital will provide care until the emergency medical condition ceases to be an emergency or until the individual is properly transferred to another facility. A physician at the receiving facility must agree to accept the patient in transfer prior to sending the patient. An "Authorization to Transfer" form must be completed for every emergency patient. All sections of the form must be completed with particular attention paid to documentation of patient condition, reason for transfer, accepting facility and name of accepting provider, what documentation was sent with the patient, risks and benefits of transfer and mode of transport. For Psychiatric Emergencies and Transfers, a mental health professional will be available at all times to provide a mental health screening for ED patients who have conditions that may indicate a psychiatric emergency condition. In addition to the mental health screening exam, a complete Medical Screening Exam (MSE) will be performed and documented. "Stabilization" of a psychiatric patient requires that the patient be "protected" from committing harm to self or others. Stabilization may include the use of either medication or physical restraints. Any patient whose psychiatric condition requires transfer to another facility must have an "Authorization to Transfer" form completed.

2. Medical record review showed that "Authorization to Transfer" forms were incomplete for Patient #4. The provider signature and condition at transfer sections were blank. The medical record for Patient #12, the medical record did not include an Authorization to Transfer form. The medical record for patient #17 showed that the reason for transfer was blank. The consent for transfer was not checked, but the patient signed the document. The medical record for Patient #20 showed that the patient did not sign the Authorization to Transfer form. There was no documentatation of why the patient did not sign the form.

3. During an interview with the investigator on 11/18/21 at 12:55, the incomplete "Authorization to Transfer" forms were confirmed by the ED Manager (Staff #6) and the Regional Director of Regulatory and Accreditation (Staff #16).