HospitalInspections.org

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examination examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for one of 27 medical records reviewed (MR16) and failed to monitor patients prior to the determination whether or not the patient had an emergency medical condition for nine of 27 medical records reviewed (MR4, MR7, MR8, MR9, MR12, MR16, MR21, MR23 and MR24).

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA) Date: April 1, 2009" revealed "I. POLICY It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. ... III. SCOPE This policy applies to all UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy. IV. DEFINITIONS 1. Dedicated Emergency Department is an department of facility of the hospital whether on or off campus that: ... (b) is held out to the public as a place that provides care for emergency medical conditions without an appointment; or (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third(1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment. 2. Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including server pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual ... in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part ... 3. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether and emergency medical conditions exists. ... V. PROCEDURE 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person."

Review of "WPIC Inpatient Programs Scope of Service Program: Diagnostic Emergency Center (DEC) ... 2/2010" revealed "The goal of the DEC program is to provide a safe, therapeutic environment for the patient's and their families and staff in which the evaluation of an acute psychiatric illness can be provided ... The DEC program provides for the safe evaluation of patient's presenting with complaints of psychiatric-related illnesses on a 24 hour, 7 days a week basis ... Program Description ... B. Scope of Care The Diagnostic Emergency Center at WPIC provides complete and comprehensive psychiatric emergency services for children, adolescents, adults, and the geriatric population. ... The Diagnostic Emergency Center is a 24-hour, 7-day a week service which function as both a full intake assessment center and psychiatric emergency service. Assessment focuses on the patient's current problem's (history or presenting illness). Signs and symptoms, past psychiatric history, mental status exam, medical history, current psychical complaints, personal and social history, family history of medical and psychiatric disorders, assessment of the above, and consequent disposition. Services include psychiatric evaluation, crisis therapy and stabilization, general medical evaluation, inpatient admission, and ambulatory referral."

Review of "Patient Assessment / Reassessment Date: January 6, 2010" revealed "I. Policy It is the policy of UPMC Presbyterian Shadyside (UPMCPS) to recognize the importance of patient assessment and reassessment in the delivery of patient focused health care. ... V. Reassessment A. The scope and frequency of a patient reassessment are determined by a patient's diagnosis, treatment setting, the patient's desire for treatment and the patient's response to treatment as outlined in the plan of care. Reassessments will be of sufficient scope to identify potential and/or actual changes in a patient's condition and thus result in a modification of the patient's plan of care as necessary."

Review of "WPIC DEC Specific Therapeutic Observation ... 5/09" revealed "Procedure: It is the policy of Western Psychiatric Institute and Clinic Diagnostic Evaluation Center (DEC) to provide safe and therapeutic observation of all patients according to patients' needs. While the patients benefit from staff interaction and observation, some patients require a more structured type of staff supervision for their own safety and sense of reality testing. Observation levels for all patients entering the DEC are standard Therapeutic Observation 15 Minutes ... Purpose: To ensure the safety and clinical management of patients in the DEC. Type Of Observation: A. TO connotes 'Therapeutic Observation' by staff. It is the minimal level of patient observations, occurs every 15 minutes, and provides an invaluable source of behavioral information as part of the assessment, diagnostic, and referral process ... Procedures Governing The Use Of TO ... A. TO 15 is the standard observation level for all patients in the DEC. Each observation is recorded and initialed by the assigned staff on a designated log for each shift ... C. The Patient Service Coordinator for each shift will be assigned to complete all levels of observation and log them accordingly."

1) A review of the DEC's computerized "White Board" patient tracking system/log, of patients presenting to the DEC area, from August 2009 to January 2010 was performed. A random sample of 28 records were selected for review.

Review of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR27 and MR28 (96% of the records reviewed) revealed these patients presented unscheduled, as outpatients, to the DEC area for treatment of emergency medical conditions.

2) Review of the DEC's computerized "White Board" patient tracking system/log revealed sections which indicated "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" and a corresponding area to input the time for each.

Interview with EMP7, during a previous complaint investigation survey, on February 18, 2010, at approximately 10:20 AM confirmed the above findings and revealed "MD Decision time is the time that the physician decided on what the patient's disposition would be, such as admission, discharge or transfer." During further interview, EMP7 confirmed that the "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" times are not part of the medical record.

3) Review of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR27 and MR28 revealed a computerized "Multidisciplinary Psychiatric Evaluation Report."

Further review of the "Multidisciplinary Psychiatric Evaluation Reports" revealed that they contained four separate assessments "Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis."

Additional review revealed only one documented date and time on either the "Multidisciplinary Psychiatric Evaluation Report" or the four "Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis" reports.

During an interview with EMP7, during a previous complaint investigation survey, on February 18, 2010, at approximately 10:20 AM, EMP7 confirmed the above findings and revealed "The report [Multidisciplinary Psychiatric Evaluation Report] is a combination of all four assessments [Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis] ... The report is a crystallized report ... all four of the reports form the Multidisciplinary report." During further interview with EMP1, EMP1 was asked to confirm that the entries are not timed and EMP1 stated "No, they are not timed. It is a [computer] issue ... The only time that comes up on the report is the triage time ... The [computer program] does not have the ability to time entries."

4) During an interview with EMP7, during a previous complaint investigation survey, on February 18, 2010, at approximately 1:00 PM, EMP7 was asked how the DEC monitors patients while they are waiting for a medical screening exam and EMP7 stated "We do 15 minute [Therapeutic] observations on all patients in the DEC."

Review of the designated logs for Therapeutic Observation, for January 4, 11, 18, and 25, 2010, revealed that the logs only indicated the physical location of the patient in the DEC and "Nutrition offered A=Accepted D=Declined N=No." Further review of these logs revealed no documented evidence that the logs provide behavioral information about the patient.

Further interview with EMP7 on February 18, 2010, at approximately 1:00 PM, revealed "They [Therapeutic Observation logs] are not part of the medical record ... We file them in a cabinet ... They are not sent to medical records."

Interview with EMP1 on February 23, 2010, at approximately 10:40 AM revealed "The 15 minute checks are an observation of the patient, it is not to see if the patient is OK, it's to know that the patient is there and physically looks OK."

5) Interview with EMP1 on February 23, 2010, at approximately 3:50 PM revealed "We consider the MSE to be a fluid process that involves many different disciplines in the DEC ... The time that is put in for the 'MD Decision' time would be after discussion with the whole team." During further interview, EMP1 was asked if the "MD Decision" time, documented in the computerized "White Board" patient tracking system/log, is the time that the physician determined whether a patient had an Emergency Medical Condition and EMP1 stated "Yes."

6) Review of PT1's medical record from Western Psychiatric Institute and Clinic (MR16) revealed that the patient present to the DEC on January 25, 2010, and was triaged at 2:45 PM. Further review of MR16 revealed that the patient presented with psychiatric issues but also had recently had a nasogastric tube removed and had been refusing to eat.

Review of computerized "White Board" documentation revealed that a "MD Decision" for MR16 was documented at 2:05 AM on January 26, 2010.

Further review of MR16 revealed an un-timed physician's progress note, dated January 25, 2010, which revealed that PT1 was allowed to be discharged, per the physician's assessment. Further review of this physician progress note revealed no documented evidence of a medical examination of the patient.

Additional review of MR16 and computerized "White Board" documentation for MR16 revealed no documented evidence of continued monitoring between the triage time of 3:28 PM on January 25, 2010, and the "MD Decision" time of 2:05 AM on January 26, 2010 (ten hours and 37 minutes)."

Interview with EMP7, during a previous complaint investigation survey, on February 18, 2010, at approximately 1:00 PM confirmed the above findings and revealed "We don't have any other documentation on [PT1]."

7) Review of MR29 (PT1's medical record from another hospital) revealed that the patient presented to their ED on January 26, 2010, at 3:00 PM. Review of the "ED Report" from this presentation revealed "[The patient] was taken to WPIC where they attempted to admit [the patient] however did not have a bed available. ..." Further review of MR29 revealed that PT1 had refused to eat or drink for two days, after having a nasogastric tube removed, and also had no urinary output for greater than 24 hours. Additional review revealed that PT1 received intravenous hydration, was admitted, and had a nasogastric tube inserted, after which tube feedings were initiated.

Further review of the discharge summary for MR29 revealed "Hospital Course The patient was admitted to the hospital for IV fluid hydration and also feeding plan recommendations. The patient's nasojejunal tube was replaced by Interventional Radiology on his second day of admission, and tube feeds were restarted ..."

8) Review of MR4 and computerized "White Board" documentation for MR4 revealed that the patient presented to the facility on August 21, 2009. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report," between the triage time of 2:13 AM on August 21, 2009, and the "MD Decision" time of 8:15 AM on August 21, 2009 (six hours and two minutes)."

9) Review of MR7 and computerized "White Board" documentation for MR7 revealed that the patient presented to the facility on January 21, 2010. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report," between the triage time of 5:12 PM on January 21, 2010, and the "MD Decision" time of 1:33 AM on January 22, 2010 (eight hours and 21 minutes)."

10) Review of MR8 and computerized "White Board" documentation for MR8 revealed that the patient presented to the facility on January 2, 2010. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report," between the triage time of 6:39 PM on January 2, 2010, and the "MD Decision" time of 10:33 PM on January 2, 2010 (three hours and 56 minutes)."

11) Review of MR9 and computerized "White Board" documentation for MR9 revealed that the patient presented to the facility on January 20, 2010. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report", between the triage time of 10:46 AM on January 20, 2010, and the "MD Decision" time of 3:30 PM on January 20, 2010 (four hours and 43 minutes)."

12) Review of MR12 and computerized "White Board" documentation for MR12 revealed that the patient presented to the facility on January 4, 2010. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report", between the triage time of 4:54 PM on January 4, 2010, and the "MD Decision" time of 2:14 AM on January 5, 2010 (nine hours and 20 minutes)."

13) Review of MR21 and computerized "White Board" documentation for MR21 revealed that the patient presented to the facility on December 21, 2009. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report", between the triage time of 4:35 PM on December 21, 2009, and the "MD Decision" time of 6:43 PM on December 21, 2009 (two hours and seven minutes)."

14) Review of MR23 and computerized "White Board" documentation for MR23 revealed that the patient presented to the facility on August 22, 2009. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report", between the triage time of 9:14 AM on August 22, 2009, and the "MD Decision" time of 12:30 PM on August 22, 2009 (three hours and 16 minutes)."

15) Review of MR24 and computerized "White Board" documentation for MR24 revealed that the patient presented to the facility on January 25, 2010. Further review revealed no documented evidence of continued monitoring, other than an un-timed "Multidisciplinary Psychiatric Evaluation Report", between the triage time of 11:05 AM on January 25, 2010, and the "MD Decision" time of 1:33 PM on January 25, 2010 (two hours and 28 minutes)."

16) Interview with EMP7 on February 23, 2010, at approximately 5:30 PM confirmed the findings in MR7, MR8, MR9, MR12, MR21, MR23 and MR24 and revealed "There are no other assessments."

Telephone interview with EMP7 on February 24, 2010, at approximately 11:10 AM confirmed the findings in MR4 and revealed "There's nothing I can find in the chart as far as assessment."