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Based on medical record review, interviews and policy review, the facility failed to ensure the medical screening examination was performed (A2406) failed to provide stabilizing treatment (A2407) and failed to ensure an appropriate transfer (A2409). The cumulative effect of these systemic practices is a risk to all patients presenting to the emergency department.

Based on staff interview and clinical record review, the facility failed to ensure one of 13 patients reviewed who presented with mental health complaints out of a total of 22 patient's reviewed was provided with an ongoing medical screening examination to determine whether the patient had a psychiatric emergency condition that would place the life of the patient or the lives and well-being of others at risk. (Patient #10)

Findings include:

The clinical record review for Patient #10 was completed on 12/20/13. The clinical record review revealed the 52-year-old patient came to the emergency department via emergency medical services on 12/16/13 at 1:55 A.M. Patient #10 had a chief complaint of chest pain for two hours, was described as "verbally aggressive", wanted to shoot self because he/she had nothing to live for, ran out of psychiatric medications stating "You need to put me up in the looney bin."

The clinical record review revealed a suicide risk assessment using the modified SAD PERSONS scale was completed on 12/16/13 at 2:08 A.M. The SAD PERSONS (Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse and Sickness) scale provides a numerical rating that is used in conjunction with clinical judgement to determine suicidal risk. Review of policy number 2.14.105, entitled suicide risk assessment, stated a score of 6 or greater indicated a potentially significant suicide risk for the patient.


According to this assessment Patient #10 scored a value of 17. The assessment scale revealed the patient was depressed and hopeless, had previous suicide or psychiatric care, excessive alcohol or drug use, loss of rational thinking and an organized or serious attempt at suicide.

The clinical record review revealed a physician physical exam that stated under "psychiatric": "He/she has a normal mood and affect. Judgement and thought content normal. He/she is agitated and aggressive."

On 12/20/13 at 12:30 P.M. in an interview, Physician #3, Director of Emergency Department, was asked can patient have a normal mood and affect but be agitated and aggressive. Physician #3 stated it couldn't be both, it had to be one or the other.

Review of policy number 2.14.105, effective 10/2012, entitled suicide risk assessment, stated in the section for exceptions for emergency department patients, "The level of care will be determined by the emergency department physician/mid-level provider in collaboration with the on call Psychiatrist based upon medical and psychiatric needs." The collaboration could not be found in the clinical records. On 12/20/13 at 3:25 P.M. Physician #3 confirmed in an interview the attending physician had not consulted with a psychiatrist.

Review of a physician progress note by Physician #5 dated nearly a day and a half later on 12/18/13 at 2:45 P.M. revealed the patient never "voiced" any complaint of suicide. On 12/20/13 at 12:30 P.M. in an interview, Physician #3 stated the clinical record did not indicate the attending physician ever asked the patient himself whether the patient wanted to kill self. Physician #3 confirmed the clinical record did not reflect whether the patient had a gun or what psychiatric medications the patient thought he/she was out of.

Record review revealed a nursing note dated 12/16/13 at 3:10 A.M. that documented Patient #10 would leave against medical advice, if wasn't given narcotic pain medicine. But when told he/she could leave, the patient stated, "You will have to drag me out." The note also stated Patient #10 told the author of the nursing note that he/she would punch the author in the face.

Record review revealed a physician progress note dated 12/16/13 at 3:11 A.M. that stated the patient refused to leave until he/she got narcotic medication, and because he/she was refusing to leave, security was called police and police took the patient out.

On 12/20/13 at 10:00 A.M. in an interview, Nurse #2, Emergency Department manager, stated the patient's blood alcohol level was .103. Nurse # 2 also stated that he/she thought the patient was going to jail because the patient was so out of control.

Prior to the patient's removal from the emergency department, a reassessment for suicide risk utilizing the modified SAD PERSONS scale was not completed as required by policy number 2.14.105 prior to discharge.

Based on interview and clinical record review, the facility failed to ensure one of 13 patients reviewed that presented with mental health complaints out of a total of 22 patients reviewed was provided with necessary stabilizing psychiatric treatment. (Patient #10)

Findings:

The clinical record review for Patient #10 was completed on 12/20/13. The clinical record review revealed the 52-year-old patient came to the emergency department via emergency medical services on 12/16/13 at 1:55 A.M. and was discharged/escorted out by police on 12/16/13 at 3:11 AM. Review of a nurse practitioner note dated 12/16/13 at 3:43 AM documented the patient presented with chest pain and suicidal.

Review of nursing note dated 12/16/13 at 2:15 AM revealed the patient arrived to the Emergency department with chest pain for two hours prior, was described as "verbally aggressive" and wanted to shoot self because he/she had nothing to live for. The note also stated the patient wanted to beat his/her roommate to death after roomate kicked the patient out of residence. The patient stated he/she ran out of psychiatric medications and "You need to put me up in the looney bin." The nursing note stated security was at bedside.

The clinical record review revealed a suicide risk assessment using the modified SAD PERSONS scale was completed on 12/16/13 at 2:08 A.M. The SAD PERSONS (Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse and Sickness) scale provides a numerical rating that is used in conjunction with clinical judgement to determine suicidal risk. The assessment scale revealed the patient was depressed and hopeless, had previous suicide or psychiatric care, excessive alcohol or drug use, loss of rational thinking and an organized or serious attempt at suicide. According to this assessment Patient #10's total score was 17. Review of policy number 2.14.105, entitled suicide risk assessment, stated a score of 6 or greater indicated a potentially significant suicide risk for the patient.

The clinical record review revealed a physician physical exam that stated under "psychiatric": "The patient has a normal mood and affect. Judgement and thought content normal. The patient is agitated and aggressive." On 12/20/13 at 12:30 P.M. in an interview, Physician #3 was asked can a patient can have a normal mood and affect but be agitated and aggressive. Physician #3 stated it couldn't be both, it had to be one or the other.

Review of policy number 2.14.105, effective 10/2012, entitled suicide risk assessment, stated in the section for exceptions for emergency department patients, "The level of care will be determined by the emergency department physician/mid-level provider in collaboration with the on call Psychiatrist based upon medical and psychiatric needs." The collaboration could not be found in the clinical records. On 12/20/13 at 3:25 P.M. Physician #3 confirmed in an interview the attending physician had not consulted with a psychiatrist.

Review of a physician progress note dated nearly a day and a half later on 12/18/13 at 2:45 P.M. revealed the patient never "voiced" any complaint of suicide.

On 12/20/13 at 12:30 P.M. in an interview, Physician #3 stated the clinical record did not indicate the attending physician ever asked the patient himself whether the patient wanted to kill self. Physician #3 confirmed the clinical record did not reflect whether the patient had a gun or what medications the patient thought he/she was out of.

Record review revealed a nursing note dated 12/16/13 at 3:10 A.M. that stated the patient would leave against medical advice, if the patient wasn't given narcotic pain medicine. But when Patient #10 was told he/she could leave, the note documented the patient stated, "You will have to drag me out." The note also stated Patient #10 told the author of the nursing note that he/she would punch the author in the face.

Staff nurse #3 documented on 12/16/13 at 2:40 AM an attempt to medicate the patient with Tylenol resulted in the patient stating Tylenol was not going to help the pain and the patient was going to leave against medical advice. Staff nurse #3 documented Physician #5 and Staff # 6 stated the patient could leave as he/she was not on a psychiatric hold.

Record review revealed a physician progress note dated 12/16/13 at 3:11 A.M. that stated the patient refused to leave until he/she got narcotic medication, and because he/she was refusing to leave, security was called police and police took the patient out. The decision making note stated he/she was aggressive with emergency department staff after not receiving narcotic pain medication. The note did not address what psychiatric medications the patient thought he/she was on or out of, and did not address whether the patient had a gun to shoot herself. The clinical record review did not reveal where the patient was ordered and provided with psychiatric medicine and if not why not.

On 12/20/13 at 10:00 A.M. in an interview, Nurse #2, ED nurse manager, stated the patient's blood alcohol level was .103. Nurse # 2 also stated that he/she thought the patient was going to jail because the patient was so out of control. The clinical record review did not reveal how the combination of suicide ideation and elevated blood alcohol level was treated.

Prior to the patient's removal from the emergency department, a suicide risk reassessment utilizing the modified SAD PERSONS scale was not completed as stated in policy number 2.14.105. Review of the clinical record revealed discharge instructions for atypical chest pain, and nothing for psychosis.


The clinical record review revealed the patient was not provided with any psychiatric treatment either through consultation with a psychiatrist per policy number 2.14.105, effective 10/2012, entitled Suicide Risk Assessment, or through medication prescribed by the emergency department physician, prior to the patient's removal from the emergency department.

Based on interview and clinical record review, the facility failed to ensure one of one patient who was removed from the emergency department by law enforcement did not occur until after the patient had received stabilizing treatment for suicidal ideation. (Patient #10) The sample size was 22 patients.

Findings:

The clinical record review for Patient #10 was completed on 12/20/13. The clinical record review revealed the 52-year-old patient came to the emergency department via emergency medical services on 12/16/13 at 1:55 A.M. and was discharged/escorted out by police on 12/16/13 at 3:11 AM. Review of ED provider notes authored by Staff #6 dated 12/16/13 at 3:43 AM reveal the patient presents with complaints of chest pain and suicidal.


The clinical record review for Patient #10 revealed a physician progress note dated 12/16/13 at 3:11 A.M. that stated the patient refused to leave until receiving narcotic medication, and because the patient was refusing to leave, security called police and police came and took the patient out.

On 12/20/13 at 10:00 A.M. in an interview, Nurse #2, ED nurse manager, stated he/she thought the patient was going to jail because the patient was so out of control.

The clinical record review revealed Patient #10 was not provided with any psychiatric treatment either through consultation with a psychiatrist per policy number 2.14.105, effective 10/2012, entitled suicide risk assessment, or through medication prescribed by the emergency department physician, prior to the patient's removal from the emergency department.

Prior to the patient's removal from the emergency department, a reassessment suicide risk utilizing the modified SAD PERSONS scale was not completed prior to discharge as stated in policy number 2.14.105. Review of the clinical record revealed discharge instructions for atypical chest pain, and nothing for psychosis.

Record review revealed a physician progress note on 12/18/13 at 2:45 P.M. a day and a half after admission that stated Patient #10 was discharged to "home" with no elaboration as to where "home" was. Review of an admission nursing note dated 12/16/13 at 2:15 A.M. revealed the patient stated the roomate had kicked the patient out of the residence.