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Based on review of medical records, hospital policies, procedures, and protocols, interviews with key hospital staff and local law enforcement agencies, on March 23-24, 2010, review of law enforcement documentation of transport, and review of accepted Emergency Medicine Standards, it was determined that the hospital failed to maintain a central log on each individual who came to the Emergency Department. For further information see Tag A2406.

Based on review of medical records, hospital policies, procedures, and protocols, interviews with key hospital staff and local law enforcement agencies, on March 23-24, 2010, review of law enforcement documentation of transport, and review of accepted Emergency Medicine Standards, it was determined that the hospital failed to provide an appropriate medical screening examination within the capability of the hospital ' s emergency department to determine whether or not an emergency medical condition exists. Therefore, as there was no documented medical screening exam completed, the hospital failed to offer stabilization treatment prior to transfer. Additionally, the hospital failed to have adequate systems in place to review identified patient care problems in the Emergency Department. These findings present an Immediate Jeopardy to the health and safety of patients served by the Emergency Department at Maine Medical Center (MMC).

Findings include:

Hospital ' s ' Emergency Screening, Stabilization and Management of Patient Transfer to another Facility ' Policy

1. The hospital ' s policy entitled ' Emergency Screening, Stabilization and Management of Patient Transfer to another Facility ' was last reviewed by the hospital in October 2009. The ' Policy Summary ' stated " The Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals with emergency departments to provide specified emergency services to any individual who comes to the hospital and requests examination or treatment for a condition that may be an emergency, including pregnant women in labor. It is the purpose of this policy to ensure that (1) all patients who come to the hospital requesting emergency services receive an appropriate medical screening examination to determine of an emergency medical condition exists; (2) patients with an emergency medical condition (as defined below) are stabilized; (3) patients requiring or requesting transfer are transferred in accordance with EMTALA requirements regardless of their diagnosis, ability to pay, race, color or national origin. "

2. This policy also stated, " An Emergency Medical Condition (EMC) is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the health of the individual (or with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy; or (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. " This section continues, " A psychiatric patient is considered to have an EMC if either (a) acute psychiatric or acute substance abuse symptoms are manifested; or (b) the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others. "

Failure to provide an appropriate medical screening exam:

3. A review of law enforcement documentation dated March 17, 2010, revealed Patient A was transported to MMC at 1630 in protective custody of the law enforcement agency for evaluation and treatment for acute intoxication and suicidal ideation.

4. An interview with the Registration Representative on March 23, 2010 at 1455 revealed that the Emergency Department Staff had " ...received a page from the REMIS [Regional Emergency Medical Information System] call center that said an ' intoxicated and suicidal patient was being brought in by the PD [police department] ' ... "

5. A review of the REMIS documentation indicated that a page was sent on March 17, 2010 at 1658 to " Triage 5A ED [emergency department] NSG [nursing] CC [chief complaint]: Suicidal ideations, ETOH [ethyl alcohol] not cooperative via South Portland Police " . It was confirmed with the Director of Accreditation during an interview on March 24, 2010 at 1448 that this page related to Patient A.

6. The Clinical Nurse III, indicated in a written " Timeline of events March 17, 2010 between 5p-6p " that he/she had " ...received a paged intoxicated and combative e patient with suicidal ideations. Called Triage 2 to book a room...asked by [evening security supervisor] to come outside via ambulance bay. 3 police officers were standing outside of a cruiser...a police officer ...informed me that in the back of the cruiser was a [patient] who was an emergency room employee. [Patient] was combative and refusing to come to Maine medical center because [patient] was an employee here in this emergency department. I asked why [patient] was here, was told [patient] was intoxicated...I opened the door [to the cruiser] the individual kicked out at me and yelled [obscenities]...I asked [patient] what was going on and [patient] stated I told them not to bring me here. I turned to the police and asked if this was true, and they [police] said yes [patient] told us [patient] was an employee at MMC and did not want to come to this hospital. [Patient] asked to go to [receiving hospital]. I asked why [patient] was not taken there and was told by the police because [patient] was combative. The officer then asked the individual if now [patient] would go cooperatively to [receiving hospital] vs having to be taken out of the cruiser forcefully. [Patient] stated...would go cooperatively to [receiving hospital] as [patient] had first requested. The police stated they would rather have [patient] be cooperative and would take [patient] to [receiving hospital] and asked if I would call to let them [Receiving hospital] know they [police with patient] were coming. I agreed... "

7. During an interview on March 23, 2010 at 1535, the Clinical Nurse III, who was the triage nurse on March 17, 2010, stated, that she went outside and saw there were three police officers behind a police car. Additionally, she saw that the patient was an ED employee who was intoxicated and combative. The nurse opened the door to the police car, addressed the patient by name and the patient proceeded to kick out at the nurse and yell obscenities.

8. Sheehy ' s Manual of Emergency Care, Sixth Edition (2005) Emergency Nurses Association (Mosby, Inc), Chapter 27, " Alcohol Emergencies " page 450, stated, " ...Before determining that a patient is " just drunk, " the emergency nurse must identify any other illnesses or injuries contributing to the patient ' s condition such as head trauma, diabetic ketoacidosis, hypothermia, or drug overdose... "

9. Sheehy ' s Manual of Emergency Care, Sixth Edition (2005) Emergency Nurses Association (Mosby, Inc), Chapter 48, " Mental Health Emergencies " page 879-880, stated, " ...All patients with suicidal ideation or suicide attempt are considered to require emergent care and should be placed immediately in an examination room. Institute one-on-one observation, and document interventions using suicide precaution and intensive monitoring forms... "

10. The Clinical Nurse III stated, during the interview on March 23, 2010 at 1535, " I then asked the police why they brought [the patient] here. The police indicated that he/she had become combative during the transport to [receiving hospital] and decided to stop here for assistance. The police came to an agreement with the patient to go to [receiving hospital] if he/she would cooperate. The police then asked me to call [receiving hospital] as a courtesy. "

11. Although Clinical Nurse III stated that the police were involved in the decision to transfer the patient to another hospital, other interviews revealed conflicting information about who initiated the request for transfer. During an interview with the Security Supervisor - Second Shift on March 23, 2010 at 1510, it was stated, " ...I received a call via radio that the patient was coming in. The PD called for our assistance for a combative patient. I got the triage nurse -Triage 5. The nurse went outside and the patient became quite aggressive, not saying nice things, combative. The nurse spoke to me and asked what I thought. I told the nurse to transfer to [receiving hospital], however, it wasn ' t my call...The nurse asked the police if they minded transferring to [receiving hospital]. They said they did not mind. The nurse then went in and called [receiving hospital]. "

12. During an interview on March 23, 2010 at 0930, the Director of Accreditation confirmed that the hospital did not have a medical record on Patient A for the ED visit of March 17, 2010. Therefore, there was no documentation of a medical screening exam.

13. The potential impact of a failure to conduct a medical screening exam is the failure to recognize the existence of an emergency medical condition.

Failure to adequately stabilize for transfer:

14. A review of the ED log on March 23, 2010, failed to contain any information related to Patient A ' s visit to the hospital on March 17, 2010. Additionally, the Security Supervisor indicated during an interview on March 23, 2010, that there was not a formal report of the incident by Security as the individual was not registered as a patient.

15. A review of Patient A ' s medical record at the receiving facility indicated that the patient had arrived to the ED at 1736 on March 17, 2010. The triage assessment documentation, revealed, " pt handcuffed, to ER via SPPD [South Portland Police Department] with 3 officers...from patient ' s home and then MMC ER driveway...actively suicidal... " The Behavioral Assessment completed on March 17, 2010 at 1751 indicated that Patient A was harmful to self, aggressive, verbally abusive, combative, agitated, crying, and uncooperative.

16. The " Emergency Physician Record " , dated March 17, 2010, indicated, " Brought in by police [after] expressing wish to kill self...Intoxicated. Refuses to speak but says, ' I ' m going to do it! ' - won ' t give details. "

17. The ED record indicated that Patient A was place in four (4) point restraints at 1815 and medicated with Haldol 5mg IM [intramuscular] for aggressive actions towards staff. Patient A was threatening to kick and bite staff, and refusing to cooperate with medical care.

18. Nursing documentation at 1847 indicated that Patient A continued to have suicidal ideation; however, the patient refused to tell medical staff his/her plan. Additionally, there was documentation that the patient was agitated and combative.

19. Laboratory results that were reported on March 17, 2010 at 2000 revealed that Patient A ' s blood alcohol level was 0.22 g/dL with a normal value of <0.01 g/dL.

20. Common Laboratory & Diagnostic Tests, Fourth Edition (2006) by Fischbach and Dunning, page 102, stated, " ...At levels >100 mg/dL (>21.7 mmol/L) [Note: this is 0.10 grams/deciliter.], individuals will become uncoordinated and disoriented with loss of memory and critical judgment skills... "

21. During an interview on March 23, 2010 at 0930, the Director of Accreditation confirmed that the hospital did not have a medical record on Patient A for the ED visit of March 17, 2010. Therefore, there was no documentation of any stabilizing treatment.

22. The potential impact of a failure to recognize that an intoxicated, suicidal patient could have taken a toxic or lethal ingestion is the possibility of further decompensation, potentially resulting in death.

Failure to have adequate systems in place to review identified patient care problems in the Emergency Department:

23. During an interview on March 23, 2010 at 0940, the Patient Safety Officer and Associate VP of Medical Affairs stated, " We didn ' t treat the patient. Our attorney gave us his interpretation of the law. We facilitated the individual ' s request to go to [receiving hospital]. We didn ' t consider this an EMTALA violation. He/she refused treatment and didn ' t come here of his/her own volition. Therefore, we didn ' t see this as an EMTALA. "

24. In spite of the fact that the patient arriving at the hospital in protective custody, in spite the fact that the Clinical Nurse III went outside to assist with the patient, and in spite of the fact that police department had transferred the patient to another facility without the patient first having an appropriate medical screening exam and/or stabilizing treatment, there was no documented evidence of any quality review at the time of survey.

25. During an interview on March 23, 2010 at 0930, the Director of Accreditation stated, " We haven ' t done any investigation. We do have an incident report with supporting documentation. That ' s it. We feel that we do not have any violations. [He/she] was never a patient here. "

Based on review of medical records, hospital policies, procedures, and protocols, interviews with key hospital staff and local law enforcement agencies, on March 23-24, 2010, review of law enforcement documentation of transport, and review of accepted Emergency Medicine Standards, it was determined that the hospital failed to offer stabilization treatment prior to transfer. For further information see Tag A2406.