HospitalInspections.org

Based on review of medical records and staff and provider interviews, the hospital failed to provide a safe discharge from the emergency department for 1 of 30 patients reviewed (Pt #3), a minor behavioral health patient, and failed to reevaluate the patient after return to the ED the same day.

The findings included:

Review on 07/31/2024 of the closed medical record for Patient #3 revealed the patient presented to the ED (Emergency Department) via EMS (Emergency Medical Services) on 12/10/2023 at 1940 with an arrival complaint of "Psychiatric Evaluation." Review of the ED Provider Note at 2006 revealed "Patient is a 16-year-old female with past medical history of aggressive behavior, disruptive mood dysregulation disorder, major depression, PTSD (Post Traumatic Stress Disorder) .... suicidal ideations reporting from DSS (Department of Social Services) ... ." Provider Note review revealed Patient #3 had also been in the ED in November 2023 and at that time was discharged to DSS. Further review of the provider note revealed " ...Patient was reportedly refusing her medications over the last 2 (two) days and becoming very agitated and aggressive, barricading herself in DSS office .... EMS was called ... ." Patient #3 was placed under involuntary commitment (IVC) due to her behaviors. Record review revealed Patient #3 had been residing at the DSS office building while they tried to find placement at the time she refused to take her medications and barricaded herself in her room. Review revealed telepsychiatry recommended "inpatient psychiatry for safety, stabilization, medication adjustments and determination of appropriate long term disposition. ..." Review revealed efforts to secure inpatient placement were not successful; Patient #3 was declined admission for inpatient psychiatry due to behaviors or placed on a wait list that could last 1-2 months. Review revealed Patient #3 exhibited violence on 12/22/2023 at 1100 and required restraints. Review of a Case Management Note dated 12/27/2023 at 1818 revealed "... SW met with pt at bedside to discuss physical violence episode that occurred this week. Pt stated 'I was mad and I was not on my medications'. Pt advised she has been taking her medications and realizes that they help her feel better .... Pt asked if she can be dc (discharged) back to DSS now since she is feeling better. Pt stated she will continue to take her medications when she discharges and would go to therapy. Pt behaved well today and was active, talking with staff, coloring, reading, and watching TV. Meeting with DSS and Local Management Entity (LME) scheduled for tomorrow, 12/28, at 8:30 am for placement updates. ..." Review of the Case Management Note on 12/28/2023 at 1003 revealed " ... SW completed Disposition/Placement meeting with DSS and LME .... SW Provided hospital update ....DSS did not provide any updates but advised they will be reaching out ... for ... recommendations and formal assessment ....LME advised all crisis facilities in NC and PRTFs (Psychiatric Residential Treatment Facilities) have so far denied pt, as well as inpatient facilities .... also advised a Peer to Peer was completed ... result of this is that pt will be strongly considered for placement. SW to follow for tele-Psychiatry assessment. ..." Review of the Tele-Psychiatry note dated 12/28/2024 at 1618 revealed "... Patient was initially seen by psychiatry on 12/11 and we are being re-consulted today given improvement in behaviors with medication compliance for the last 4 days ... Per collateral, patient continues to have low distress tolerance. Guardian reports improvement though not complete return to baseline. DSS unable to take patient back to their care until further improvement is noted.... It does appear patient's status has improved with med compliance since last evaluation, however given severity of recent aggressive episodes, recommending continuing to pursue inpatient options... The patient DOES meet North Carolina involuntary commitment criteria at this time. ..." Review of the Tele-Psychiatry note dated 01/02/2024 at 1732 revealed "...We have been reconsulted again today given ongoing safe behaviors.... Although this patient presented for aggression and labile mood, they do NOT appear to be at imminent risk of dangerousness to self and dangerousness to others at this time .... the patient does not necessitate nor desire further acute inpatient psychiatric care at this time ... Unable to make formal recommendations for disposition due to inability to contact guardian and discuss aftercare planning. With respect to commitment criteria, it does not appear that the patient would currently meet this. ..." Review of the ED Provider note on 01/03/2024 at 1340 revealed "... Past 24 hour events: Currently resting there is been [sic] multiple discussion that this setting and [sic] certainly is not the most appropriate setting for this patient. ..." Review of a Case Management Note on 01/03/2024 at 1350 revealed "...pt has been placed for discharge from Emergency Department. SW made phone calls to both (DSS guardian #2 and DSS Supervisor) .... Left .... voicemail advising pt is discharged and if SW needs to arrange for transportation .... 1406 - SW received a call (from DSS Appointed Staff #5) .... advised he was forwarded a voicemail SW left worker (Guardian #2). SW confirmed pt is recommended for dc (discharge) and ready to be picked up .... (DSS Appointed #5) advised DSS stance has not changed .... they do not feel the DSS office is a safe place for the pt, so they will not be coming to pick the pt up. ..."

Review of the ED Provider note on 01/04/2024 at 0812 revealed "... Past 24 hour events: ... Per chart review it does appear that patient will be discharged back to DSS by law enforcement ... Updated Plan: Working with case management for discharge back to DSS. ..." Review of the Tele-Psychiatry Consult note dated 01/04/2024 at 1341 revealed " ... RELEVANT UPDATES TO HOSPITAL COURSE: Since the prior evaluation 2 days ago the patient has remained behaviorally stable .... She said that she was frustrated at still being in the hospital and that the DSS case worker had told her that she would not be going back with them but she did not know what the plan was. COLLATERAL INFORMATION: Participated in a video call with (SW #4) who is the social worker at the emergency department and a DSS supervisor. I explained that I had not made a formal recommendation for placement previously because I had not spoken with (Guardian #2) at that time. I wanted to know if the patient had communicated any other information such as suicidality, intention for aggression or other information regarding concerning psychiatric symptoms. The supervisor told me that he did not believe that the information the patient was conveying to (Guardian #2) was different from the information that I had had [sic]. I explained that given the sustained period of stable behavior I could not recommend that the patient be hospitalized acutely." Review of the ED Provider note on 01/08/2024 at 1545 revealed " ... After the last several evaluations she is felt no longer to require inpatient hospitalization. She is no longer involuntary [sic] committed. At this time she is safe for the outpatient community in the care of the DSS. ..." Review of the Case Management Note on 01/10/2024 at 0905 revealed "... 0800 - SW received communication from hospital administration to arrange transportation to DSS office. SW attempted call to [DSS Appointed #5] at his desk and cell phone, SW left a message requesting a call back. SW completed the following email to DSS and LME representatives: 'Good morning all, Per hospital administration, our mutual patient will be leaving the Emergency Department today. I am happy to coordinate transportation to the DSS office with [DSS Appointed #5 first name] and [Guardian #2 first name] if able. If not, I will coordinate transportation to the DSS office [DSS D] with law enforcement. If there are any questions or concerns, feel free to reach out to me! Thank you' ... 1230 - Pt transported to [DSS D county office] via [ PS {public safety} #1]."

Interview on 07/31/2024 at 1451 with SW #4 revealed DSS brought Patient #3 to the ED for a "psych eval". Interview further revealed when Patient #3 was no longer recommended for inpatient admission, DSS quit answering calls and emails when the hospital tried to notify them Patient #3 was ready to be discharged. Follow-up interview on 08/01/2024 at 1305 revealed SW #4 was involved with all adolescent patients that are evaluated by tele-psych. SW #4 found inpatient placement for Patient #3 at (Facility E) however they rescinded the bed offer due to notes that showed aggressive history. Continued interview at 1646 with SW #4 revealed a WebEx meeting was held with DSS, [Hospital A]'s Administration, LME, and SW #3 where the decision was made to send Patient #3 back via LEO. DSS did not agree with the discharge and wanted Patient #3 to remain at the hospital until proper placement was found. SW #4 stated "can't appeal discharge from the ED." SW #4 felt it was a safe discharge since Patient #3 was being discharged back to her legal guardian and to where she was prior to admission. It is the understanding it is the practice of DSS to house children in their offices who do not meet inpatient criteria and they are trying to find placement. Interview revealed Patient #3 was discharged during business hours to assure someone was at the DSS office to receive the patient from LEO. DSS quit communicating with SW #4 and with our legal team who was already involved when they appointed [DSS Appointed #5] to be the primary contact between DSS and the hospital SW. [DSS Appointed #5] was involved in the WebEx and was notified by the Providers, that Patient #3 no longer needed to be in the hospital and notified it was not a safe environment for a patient to stay in the ED long term when not needed.

Interview on 08/01/2024 at 1148 with Provider #8 revealed the provider remembered seeing Patient #3. Patient #3 was not communicative at all. She was being evaluated for aggression and had recently been hospitalized. Interview revealed Provider #8 saw Patient #3 on 12/11/2023 for her initial consult and inpatient admission was recommended. Patient #3 was not sleeping, she hit security, broke the sink off the wall, and tried to stab the EMS worker with a syringe. Interview revealed Patient #3 was re-evaluated on 12/28/2023 and again was recommended for inpatient admission. On 01/02/2024 Patient #3 was evaluated by one of Provider #8's colleagues who determined Patient #3 did not meet IVC criteria anymore. Interview revealed on 01/04/2024 Patient #3 was again re-evaluated and inpatient admission to psychiatry was not recommended. Interview revealed telepsych providers usually do not make specific recommendations because each county has different resources available and telepsych would not know all the resources available.

Interview on 08/02/2024 at 1117 with RN #7 revealed the RN remembered Patient #3. Interview revealed DSS did not want to come pick Patient #3 up when she was ready for discharge. RN #7 did not think Patient #3 met the criteria for inpatient admission. Interview revealed some days Patient #3 was out of control and would hit staff members and/or take off running if she did not get to use her IPAD. She would throw a tantrum. DSS kept telling Patient #3 daily they were trying to find her somewhere to go. Interview revealed RN #7 thought the "ED department is not the best for kids."

Patient #3 DED visit 01/10/2024

Review of the electronic log of emergency department encounters for Patient #3 revealed Patient #3 had a visit entered on 01/10/2024 at 1630 (3 hours and 6 minutes after discharge to DSS via LE).

Review of a Case Management note, dated 01/10/2024 at 1649, revealed that at 1630 the Social Worker (#4) got a call from an ED RN that Patient #3 had just walked into the hospital. Review revealed SW #4 found the patient in the lobby without a guardian, that the patient stated DSS took her belongings, including her computer, and she got upset and left. SW #4 made a call to DSS and " ...all got on the call .... stating pt has been displaying 'behavioral issues' within the 'first four minutes' of pt being at their office. DSS representatives stated pt walking to ED also show impulsivity and they would like pt to be evaluated. ... (SW #4) advised this is not a reason to IVC or telepsych pt, and (SW #4) will reach out to Hospital administration on what to do from here. ..." Review revealed the social worker was advised they were to take Patient #3 back to DSS and Patient #3 left the hospital willingly with law enforcement. Record review did not reveal that Patient #3 was reevaluated as requested by the guardian.

Telephone interview on 08/01/2024 at 1441 with Patient #3's legal guardian revealed Patient #3 was driven to (Hospital B) when she returned on 01/10/2024 due to Patient #3's escalating behaviors.

Hospital B (Patient #3) visit 01/10/2024

Review on 08/05/2024 of the open medical record from Hospital B revealed Patient #3 arrived at the hospital on 01/10/2024. Review of the EVALUATION FOR ADMISSION /CONTINUAL STAY form revealed " ... The above named [check box] minor ... was examined on 01/10/2024 at 2000 o'clock ... DESCRIPTION OF FINDINGS: ... Patient requests admission. Has continued to engage in disruptive, aggressive, and some self injuries (sic) behaviors saying to DSS staff she will escalate if not admitted ..." Review of the Provider note dated 01/10/2024 at 2041 revealed "... Reason for Admission:... a 16-year-old Caucasian female ... presented to the Admissions Office ... as a volunteer ... walk-in early on the evening of 01/10/2024. She was brought ... by staff from [DSS D] .... Because of behavioral problems (arguments, physical aggression, property destruction), the patient was taken to the emergency department at [Hospital A Campus A] on multiple occasions. However, after undergoing telepsychiatry evaluations, it appears that the decision was made not to admit her to the hospital because of a lack of suicidality or sufficient risk of harm to others .... After eloping from the [DSS D] offices and walking back to [Hospital A Campus A] earlier today, the patient was brought to [Hospital B] to seek admission ... PLAN: 1. The on-call attending psychiatrist... made the decision to admit the patient to [Hospital B] this evening. ..." Review of the "Psychiatric Assessment" at 2025 revealed "... 3. Present Illness ....16-year-old female with a long history of psychiatric illness with multiple placements and hospitalizations throughout the years. She is in the custody of DSS. She was admitted as a volunteer and volunteer by guardian for mood stabilization and behavioral stabilization ... Upon seeing her and interviewing her, she is calm, pleasant, cooperative. She tends to minimize her role in all of this, minimizing the degree of aggression and disruptive behaviors she has been engaging in. She tends to externalize things onto others ....In any case, she has definitely been aggressive, disruptive, and oppositional in these situations .... 34. Admission: Approved ..."

In summary, Patient #3 was taken to the Emergency Department of Hospital A on 12/10/2023 where she initially displayed very aggressive behavior requiring involuntary commitment and inpatient care. The hospital attempted to get the patient admitted for inpatient psychiatric care but was not able to find placement. Over the next few weeks, behaviors improved and telepsychiatry determined an IVC was no longer needed. Other placement options had not been located. DSS indicated that they did not believe discharge to the DSS office was a safe discharge plan and refused to come pick the patient up. Patient #3 was discharged to DSS on 01/10/2024 by law enforcement (LE). Around three hours after discharge, Patient #3 walked back into the hospital, stating she had become upset with DSS and left the office on foot. The hospital reached out to the DSS guardian, a conversation was held and DSS requested the patient be reassessed for behaviors and impulsivity. The hospital did not reevaluate Patient #3 and sent her back to the DSS offices via LE without reassessment. That same day, DSS staff/guardian took Patient #3 to Hospital B where the patient was evaluated and voluntarily admitted. The hospital did not ensure a safe discharge plan and did not reevaluate Patient #3 upon return to the ED.