HospitalInspections.org

Based on medical record documentation and interviews, the hospital (Hospital A) failed to include an assessment of Patient Identifier (PI) # 1's (a psychiatric patient) post-hospital medical needs and the availability of medical services at the prearranged discharge location (probate court, although waived in this case, then Hospital B) on 06-02-10 at 11:00 AM (date / time of discharge from Hospital A).
On 06-02-10 Doctor Identifier #1 (DI #1) discharged PI #1 into the custody of the county sheriff's department as per probate court order / commitment procedure. PI #1 arrived at the probate court's designated psychiatric hospital (Hospital B) on 06-02-10 at 12:00 PM.
On 06-02-10 at 9:00 PM PI #1 was transferred from Hospital B to another local hospital's emergency room (Hospital C) for further evaluation and treatment of an elevated BUN 104 (normal range 6-20) and Creatinine 5.3 (normal range 0.5-1.2), lethargy, weakness, and obtunded conditions (MedicineNet.com defines as- mentally dull). On 06-03-10 PI #1 was transferred to a third hospital (Hospital D) and admitted to the Intensive Care Unit (ICU) for a higher level of care (of nephrology) and for evaluation and treatment of acute renal failure.
This deficient practice affected 1 of 16 sampled patients, (PI # 1).

The findings include:

1. DOCUMENTATION:

PI #1's medical record review for the hospitalization of 5-27-10 to 6-2-10 at Hospital A provided the following information.

CONSULTATION REPORT - DI #2
05-27-2010
Recommendations: (PI #1) was evaluated in (Hospital A) Emergency Room (ER) and subsequently was admitted to psychiatry services. He (PI #1) currently has a blood pressure of 144/82 and has tachycardia. At this time, would recommend continuing hydrochlorothiazide (HCTZ) 12.5 mg po daily and acquire an EKG (electrocardiogram). Labs were reviewed and noted for normal... He (PI #1) denies any current shortness of breath, chest pain, palpitations, fever or swelling of his extremities. However, history is limited secondary to the patient is not conversing. Would recommend a urinalysis repeat with his findings of blood and red blood cells initially. We will plan to check a CBC (complete blood count) and CMP (comprehensive metabolic panel) as well at this time...

DISCHARGE SUMMARY - DI #1
06-02-10
Diagnosis on discharge: Axis I- Schizophrenia, paranoid type... Axis III- History of hypertension and gout... Axis V- Global assessment of functioning (Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition [DSM -IV] defines as- the overall level of psychological, social, and occupational functioning rated on a scale from 0-100) on admission 20 (DSM-IV defines as- indicates the patient is a candidate for inpatient care who may exhibit behaviors of being some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication). Upon discharge 20.
Admission Profile: (PI #1)... with a long history of schizophrenia. He (PI #1) has been gradually getting decompensated. He (PI #1) is confused, disorganized and not able to verbalize his feelings... The patient does not have much understanding about what is going on. He (PI #1) seems to be hearing voices and frequently grunting and making noises.
Hospital Course: The patient was hospitalized to psychiatric services. He (PI #1) was placed on Saphris 10 mg sublingual twice a day. It did not make much difference in him for five days. He (PI #1) remained psychotic, agitated and disorganized. At times he (PI #1) would scream and talk to himself and get confused and cry. He (PI #1) was also focused on one or two things. Medicine (DI #2) was called in to make sure that he is medically cleared. There is no medical reasons for him to be in such a mental state at this point... We checked a CPK (Creatine Phosphokinase) level also. At the time of discharge the patient does not seem to have made much difference. He (PI #1) remained psychotic and disorganized. He (PI #1) has been recommended for petition.

PROGRESS NOTES:
05-27-10 10:36 AM Social Worker (SW) Discharge Note: Pt's mother & daughter came to unit to check on pt. RN asked about filing petition. Pt's (mother) states let MHC (mental health center) file.
05-27-10 12:55 PM SW Discharge Note: MHC officer to seek petition...
05-28-10 08:30 AM Family Practice Note: ...Cont (continue) HCTZ. Will review blood pressure and be available if needed. (DI #2)
05-28-10 08:40 AM SW Discharge Note: Patient here awaiting commitment hearing on 06-02-10 @ (at) 11 AM. Probate Judge to determine D/C (discharge) resource...
05-29-10 06:30 Family Practice Note : ...BUN (blood urea nitrogen) 12, Creatinine 1.2... Hypertension: Stable on Norvasc 5 mg daily... Had (decreased) K+ (potassium) on HCTZ. Started Norvasc BP (blood pressure) stable. Will continue to monitor & (and) be available for future concerns.
05-30-10 06:02 AM Psych Note: Poor insight... Had EPS (extra pyramidal symptoms). Given Benadryl 50 mg IM. (Decreased) Saphris 10 mg at HS.
05-31-10 08:00 AM Psych Note: Poor insight. Not very talkative... Continue on current psychotropics. BMP (basic metabolic panel) in AM.
06-01-10 10:03 AM SW Discharge Note: Court packet faxed to (Hospital B)...
06-01-10 10:10 AM Psych Note: Pt (PI #1) remains confused, psychotic, not able to talk... Has distant look. Foul body odor. Continues not able to answer well.
Diagnosis: Psychosis, schizophrenia, ? EPS.
Plan: 1. Will add Seroquel. 2. D/C Saphris. (Check) CPK. 3. Add Cogentin. 4. Needs commitment.

PHYSICIAN'S ORDERS...
05-30-10 08:00 (AM)
BMP in AM. (DI #1) (Written just above with an arrow to this order is "PT Refused".)
06-01-10 10:00 (AM)
...(Check) CPK. (DI #1) (No documentation found in record that patient refused, however, in an interview it was stated that patient refused to have blood drawn.)
06-02-10 10:05 (AM)
D/C to Probate Court - (Hospital B). (DI #1)

STATE PSYCHIATRIC HOSPITAL CRITERIA FOR DETERMINING MEDICALLY INAPPROPRIATE ADMISSIONS
Psychiatric Medical Clearance Checklist
1. Does the patient have a NEW psychiatric condition? (not marked)
2. Any history of active medical illness needing evaluation? NO
3. Any abnormal vital signs prior to transfer? NO
a. Temperature above 100.5F or below 97.5F.
b. Pulse outside of 50 to 120 beast/minute.
c. Blood pressure systolic < 90 or > 200, diastolic > 120
d. Respiratory rate > 24 breaths/minute.
e. Oxygen desaturation.
4. Any abnormal physical exam (unclothed)... NO
5. Any abnormal mental status indicating medical illness such as lethargic, stuporous, comatose, fluctuating mental status? NO
If "yes" to any of the previous questions, additional testing may be indicated.
6. Were any additional labs done?
TSH (thyroid stimulating hormone), FT4 (free thyroxine index) see attached.
7. Were X-rays performed? NO
8. Has the patient been medically cleared in the ED or by another physician other than a psychiatrist? YES
9. Was there any medical treatment needed by the patient prior to medical clearance?
FP (family practice) work up for HTN / medical. Med (medically) cleared 05-29-10. YES
10. List of current medications and times last administered attached? YES
11. Transfer Diagnoses:
Psychiatric- schizophrenia.
Medical - HTN, gout.
Substance abuse- no.
12. Any medical follow-up or treatment required at the State Psychiatric Facility?
Dehydration.
Physician Signature: (DI #1) Date: 06-01-10

NURSING VITAL SIGNS FLOW SHEET
05-30-10 07:35 Temperature (F): 97.3 F oral.
05-30-10 07:35 Respirations: 20.
05-30-10 07:35 Pulse: 131.
05-30-10 07:35 BP: 135/102.

05-31-10 07:33 Respirations: 22.
05-31-10 07:33 Pulse: 135.
05-31-10 07:33 BP: 135/99.

05-31-10 17:00 Respirations: 20.
05-31-10 17:00 Pulse: 145.
05-31-10 17:00 BP: 145/91.

06-01-10 No documented vital signs for this 24 hour time frame.

06-02-10 07:43 Temperature (F): 96 F oral.
06-02-10 07:43 Respirations: 18.
06-02-10 07:43 Pulse: 115.
06-02-10 07:43 BP: 103/82.

INTAKE and OUTPUT FLOW SHEET
05-27-10 11:48 Percent Breakfast Intake - 100
05-27-10 11:48 Percent Lunch Intake - 10
(No documentation for supper meal present.)

05-28-10 11:57 Percent Lunch Intake - 5
05-28-10 08:10 Percent Breakfast Intake - 0
(No documentation for supper meal present.)

05-29-10 No documentation present of any meal/fluid intake or output.

05-30-10 12:02 Percent Lunch Intake - 0
05-30-10 07:56 Percent Breakfast Intake - 0
(No documentation for supper meal present.)

05-31-10 13:40 Percent Lunch Intake - 0
05-31-10 08:07 Percent Breakfast Intake - 10
(No documentation for supper meal present.)

06-01-10 13:01 Percent Lunch Intake - 0
06-01-10 08:01 Percent Breakfast Intake - 0
(No documentation for supper meal present.)

06-02-10 No documentation present of any meal/fluid intake.

Note: No documentation found in record that a doctor was informed of PI #1's meal consumption.

NURSING DISCHARGE ASSESSMENT:
06-02-10 10:58 - Employee Identifier (EI) #1
Discharge info (information): Pt DC'd via walking. Self care needs indepen (independent).
Accompanied by: Deputy...
D/C oxygen status: Pulmonary status WNL for prognosis/diagnosis.
Discharge pain assessment: Discharge pain level 0.
DC neuro status: Oriented to person.
DC emotional status: Withdrawn at DC.
Attitude to DC: Accepting.
Health response: Pt denial of dx.
D/C skin status: Skin warm, dry, pink, intact, no blisters, bruises, discoloration...
D/C activity status: Partial bath, dresses with assistance.
D/C elimination: Urine output WNL R/T (related to) prog/dx (prognosis/diagnosis), bowel function WNL R/T prog/dx.
D/C nutrition status: Tolerate diet as ordered.
D/C stability: Vital signs stable...

PI #1's medical record review for the hospitalization of 6-2-10 to 6-2-10 at Hospital B provided the following information.

PROGRESS NOTE
6-2-10 12:04 PM Admission: Patient arrived 12:00 PM. RN notified at 12:02 PM. (PI # 1) was escorted by Deputy, (name of) County. He was not cooperative with admission process. He was unable to state if he was an organ donor.

COMPREHENSIVE NURSING
ASSESSMENT
6-2-10 12:30 PM by the RN (Registered Nurse).
Completed: 6-2-10 2:00 PM.
"Unable to obtain information related to being sedated on admit and unable to focus on questions." (This was the prevailing comment by the RN throughout the assessment.)

ADMISSION PSYCHIATRIC EVALUATION
06-02-10 @ 3:00 PM - Psychiatry
1. Identifying Data:
...The patient (PI #1) is transferred here today from the (Hospital A) psychiatric unit, involuntarily, under court commitment for continued inpatient psychiatric evaluation and treatment...

4. HISTORY OF PRESENT ILLNESS:
...At the present time, he (PI #1) is markedly sedated and he is unable to answer any questions and cooperate with the evaluation. On calling his (PI #1) name he opens his eyes and stares at the examiner. He (PI #1) mumbles a few words, but it is hard to understand. His lips and mouth are dry and periodically, he has dry heaves. No vomiting is observed. His extremities are cold, but his torso and head are warm. He (PI #1) complains of marked weakness and he is extremely unsteady on his feet. When he (PI #1) came to the hospital he was transported to his room via a wheelchair...

14, PLANS FOR FURTHER EVALUATION AND TREATMENT:
The patient (PI #1) is admitted to the second floor unit... He (PI #1) appears to be dehydrated and also he appears to be having other medical problems. Therefore, the patient will be referred to (medical physician) for medical evaluation and treatment. At the present time, I am going to hold all the psychotropic medications until he is medically cleared and awake...

MEDICAL CLINIC INITIAL ASSESSMENT AND REFERRAL
06-02-10 6:20 PM
Problems Identified:
Pt (PI #1) appears sedated. His (PI #1) BP is low and he is tachycardic. Skin dry...
Recommended Interventions:
Stat CBC, chem (chemistry). May need IV fluids.
Orders 06-02-10 8:55 PM:
Send pt (PI #1) to (Hospital C) for evaluation & possible admission.
BUN 104, Creatinine 5.3.

PI #1's medical record review for the hospitalization of 6-3-10 to 6-10-10 at Hospital D provided the following information.

HISTORY AND PHYSICAL - 06-03-10
The patient (PI #1)... He (PI #1) is transferred to (Hospital D) from (Hospital C) due to acute renal failure and increasing BUN and Creatinine. The patient (PI #1) was admitted to (Hospital C) in the early morning hours of 06-03-10 due to lethargy, obtunded conditions, weakness, and BUN of 104 and a Creatinine of 5.6. The patient (PI #1) also was found to have a total CPK of over 96,000 and has minimally elevated serum myoglobin level. The patient (PI #1) was admitted to intensive care unit of (Hospital C). A foley catheter was placed in. It was a nontraumatic catheter insertion. The patient (PI #1) had red blood cell in the urine. The patient had a urine output of 10-13 ml per hour... Because of the deterioration in the renal function when the BUN had gone up to about 120 to 122 and with the poor urinary output, decision was made to transfer him (PI #1) to the (Hospital D) where nephrology consultation can be obtained... Diagnoses:
1. Acute renal failure, probably due to acute rhabdomyolysis.
2. The patient had an elevated total protein of 9.5 and a globulin of 5.4 and some probability that this may be multiple myeloma with renal involvement.
3. Dehydration.
4. History of hypertension though normotensive at present.
5. Type 2 diabetes mellitus. Currently blood sugar is normal.
6. Schizoaffective disorder.
Plan of Care:
1. ICU admission.
2. Nephrology consultation.
3. IV fluid and other management as per the order sheet. Follow up the serial CPKs and monitor the urine output closely. We have started him (PI #1) on Rocephin 1 g (gram) q (every) 23 hours to provide some antibiotic coverage in view of his general condition and leukocytosis at white count of 19,300 as above.

PROGRESS RECORD
06-04-10 10:10 AM Nephrology:
ARF (acute renal failure) worsening (increased Cr (Creatinine) 6.3 c (increased) BUN 135. Surgical consult for permacath or vascath to plan HD (hemodialysis) today...
06-04-10 12:26 PM Surgical:
Right IJ (internal jugular) permacath.
06-04-10 Nephrology:
Will continue c HD x 2.5 hours today...
06-09-10 8:24 AM Medical:
BUN 24, Cr 1.6...
06-10-10 8:30 AM Medical:
Pt (PI #1) condition stable. Renal function improved markedly. He (PI #1) is afebrile. Vital signs normal, lungs clear, heart RR (rate regular). Will discharge to (Hospital B) by state car.

2. INTERVIEWS:

*EI #1 (RN Charge Nurse Behavioral Health Services who discharged PI #1 on 06-02-10) was interviewed on 06-10-10 at 11:55 AM and again on 07-06-10 at 10:30 AM. EI #1 gave the following information regarding PI #1's condition on day of discharge. "On the day of (PI #1's) discharge, he (PI #1) was standing in his room staring at the mirror above the sink (approximately 7 AM). He (PI #1) did that a lot, just stand and stare. Within the hour he (PI #1) was sitting in his room on the floor, back against the closet door. (PI #1) was wearing a hospital gown and was incontinent of urine. It was a large amount of urine and did not have a strong ammonia smell to it, just smelled like urine. (PI #1) was pretty much incontinent of urine the whole time he was with us... I told him (PI #1) we had to give him a bath and cleaned up... I got someone (unidentified staff member) to help get him (PI #1) up because he is a big man. (PI #1) stood up and he (PI #1) walked to the tub room on his own as we walked on either side of him. He (PI #1) got in the tub. He (PI #1) helped a little bit with his bath but mostly I bathed him. He (PI #1) got out of the tub and I dried him off. When I dried him (PI #1) off, his skin was warm and dry, normal color, and normal skin turgor. (PI #1) did not appear to be dehydrated that morning. He (PI #1) walked to the geri chair and sat down by the nurses' station... Then breakfast came up. Breakfast, he (PI #1) refused to eat. (PI #1) wouldn't eat much at all even with encouragement. He (PI #1) would sit down to eat take a bite, then play with his food and not eat. Some days he (PI #1) would just refuse, shake his head and say 'I'm not eating.' This morning (6-2-10, day of discharge) he (PI #1) drank a couple of cupful's of water. Family Practice (DI #2) said to encourage fluids on him (PI #1) and told me verbally to get him to drink at least two to three pitchers which holds 1000 cc (cubic centimeters) of fluid... The deputy sheriff came to the unit to take (PI #1) to (Hospital B). (PI #1's) presence at the hearing (probate court) was waived by his lawyer. (PI #1) was put in a wheelchair because it takes a long time to get from the floor to the deputy sheriff's car. Me and another aide (unable to recall staff member's name) were with (PI #1). He (PI #1) was reluctant to go with the deputy sheriff. We got (PI #1) to the deputy's car... (PI #1) wasn't doing anything out of place or out of the normal. (PI #1) knew what you were saying. (PI #1) mostly wouldn't talk, sometimes he would grunt in response to us. This was (PI #1's) behavior throughout this hospitalization. It was really bizarre because on previous hospitalizations (PI #1) would talk. (PI #1) didn't appear or act any different on 06-02-10 then when I saw him on 06-01-10, and 5-30-10. (PI #1) was very psychotic, the most psychotic that I have seen (PI #1) since he's been here. I've known (PI #1) for some time from past hospitalizations..."

*DI #1 (Psychiatry, Attending) was interviewed on 06-10-10 at 11:35 AM and gave the following information regarding the patient, (PI #1). "(PI #1) was stable medically on 06-01-10, not dehydrated. We had called in a consult for medical when he (PI #1) was admitted to the unit. His initial blood work was okay. He (PI #1) was crying, emotionally labile. That's just (PI #1). He's been here several times and we know how (PI #1) is. We consider that more of a psychosis than a medical problem. We didn't intentionally send him (PI #1) with a medical problem. I stopped Saphris related to extrapyramidal signs and symptoms and started him (PI #1) on Seroquel on 06-01-10. A medical physician cleared him. Once the patient is cleared medically we don't necessarily have the patient cleared again unless there is a problem. I did not see him (PI #1) the morning (6-2-10, Wednesday) he left (was discharged). On Wednesday's I make my rounds on the afternoon. The staff said that they were giving him (PI #1) fluids and encouraging him to drink. I did note that he (PI #1) needed to be monitored for dehydration on the form which (Hospital B) requires us to complete (Alabama State Psychiatric Hospital Criteria for Determining medically Inappropriate Admissions)..."

*DI #2 (Family Practice, Attending) was interviewed on 06-10-10 at 3:00 PM and gave the following information regarding (PI #1). "Yes, (PI #1) was medically stable when I last saw him on 05-28-10. We were consulted for a Medical Consult on (PI #1) while he was a patient on (psychiatric unit). He ( PI #1) had been off his BP meds. We saw him (PI #1) in our clinic. As far as medically stable he (PI #1) looked great. In reviewing the notes by (another doctor in Family Practice group and is out of town) who saw (PI #1) on 05-29-10 and she (another doctor in Family Practice group) didn't see anything either. His (PI #1) last labs were on 05-28-10 and his BUN was 12 and Creatinine 1.3. On 05-28-10 he was stable. His (PI #1) BP is under better control. (PI #1) sat up, talked to me and answered questions appropriately that day. His (PI #1) baseline heart rate is 100 and that's a long standing issue (for this patient) in the clinic. I wish I could tell you more but we did not see him after 05-29-10. I have heard that (PI #1) was not doing well when he arrived at (Hospital B). That's hard to understand from what I had seen of him (PI #1) on 05-28-10. I don't think that we missed anything at that time. I had ordered another urinalysis on him (PI #1) because of the blood in his urine but I'm thinking he refused to give the specimen but I'm not sure."

*EI #2 (Social Worker, discharge planner for Behavioral Health Services) was interviewed on 07-6-10 at 11:00 AM stating "(PI #1) was so very much different on this hospitalization. He (PI #1) was too impaired to have a conversation with me. Before on previous admissions I would see him (PI #1) walking the halls and (PI #1) would talk to me every time he saw me. He (PI #1) was able to discuss what was going on with him... I remember that his (PI #1) family members wanted him committed. MHC case manager was filing for petition for court commitment... My part of the discharge planning was done since MHC was filing petition for court commitment."
*EI #3 (RN, Behavioral Health Services Manager) was interviewed on 06-10-10 at 9:30 AM and again on 06-25-10 at 9:30 AM. EI #3 gave the following information regarding PI #1's 05-27-10 to 06-02-10 hospitalization.
"We've had (PI #1) as a patient several times. He (PI #1) has always been psychotic, usually a very happy psychotic... On presentation (05-27-10) (PI #1) was very withdrawn, blunt, flat affect. He (PI #1) was mumbling to himself. He (PI #1) was not his happy self. (DI #1) consulted Family Practice (DI #2). We made sure he (PI #1) was eating and drinking because of potential for dehydration related to the meds he was on. He was afebrile. He (PI #1) wasn't on intake and outputs. There wasn't an order for intake and output. If (PI #1) was sleeping we would let him sleep. We did feed him. I can tell you that on a daily basis he (PI #1) was ambulating on the unit. He (PI #1) would wander into other patients rooms. (DI #2) Family Practice cleared the patient medically. On the physician history and physical, (DI #1) noted that he's never seen (PI #1) this confused. This is one reason that (DI #1) consulted (DI #2). (DI #2) usually goes overboard on tests, etc. to make sure they didn't miss anything with the patient. (DI #1) noted that he (PI #1) appeared medically stable and also said to monitor the patient for dehydration on this form (State Psychiatric Hospital Criteria for Determining medically Inappropriate Admissions) that (Hospital B) requires us to complete. Basically, he (PI #1) needed long term psych care. (PI #1) refused to have his blood drawn for a CMP on 06-01-10 and a CPK on 06-02-10. Then he (PI #1) was taken to (Hospital B). We would not have sent (PI #1) if he was ill. Why didn't (Hospital B) call us back that day (6-2-10), the day they found that his BUN and Creatinine was elevated? We would have taken him (PI #1) back..."


This deficiency was written as a result of the investigation of Complaint #AL00022643 / CoP Discharge Planning.

Surveyor:
Susan A. Reed, RN