HospitalInspections.org

On the days of the Emergency Medical Treatment And Labor Act ( EMTALA) investigation (SC00017980) based on reviews medical records, E- (Electronic)-mail, Physician Credentialing files, staff interviews, and review of Emergency Department policies and procedures, it was determined that the hospital violated its provider agreement with CMS (Centers for Medicare and Medicaid Services).


The findings included:



Cross Reference to A 2406: On the days of the EMTALA investigation (SC00017980) based on reviews of Clinical records, Policies and Procedures, E-mail, and staff interviews, it was determined that the hospital failed to ensure that an individual coming to the Emergency Department requesting examination or treatment of a medical condition and or psychiatric condition was provided an appropriate medical screening examination within the capability of the hospital's emergency emergency department, including ancillary services routinely available to the Emergency Department to determine whether or not an emergency medical condition exists for 1 (Patient #1)of 41 patient records reviewed.


Cross Reference to A 2407: On the days of the EMTALA investigation based on interviews and review of medical records and policies and procedures and Physician credentialing files, the facility failed to ensure that patients presenting to the emergency department with identified behavioral emergencies received further medical examination and treatment that were within the capabilities of the ED to stabilize these individuals as required for 3 of 41 (#1, 39, and 40) medical records reviewed.

On the days of the EMTALA investigation (SC00017980) based on reviews of Clinical records, Policies and Procedures, E-mail, and staff interviews, it was determined that the hospital failed to ensure that an individual coming to the Emergency Department requesting examination or treatment of a medical condition and or psychiatric condition was provided an appropriate medical screening examination within the capability of the hospital's emergency emergency department, including ancillary services routinely available to the Emergency Department to determine whether or not an emergency medical condition exists for 1 (Patient #1)of 41 patient records reviewed.

The findings are:

1. Policies and Procedures
Emergency Center Policy, titled, Triage, with an origination date 8/2000 and last revision date 10/08, reads, "Definitions: . . Emergency Severity Index..."A five level triage instrument that categorizes patients by both acuity an expected resource needs. Acuity is defined in terms of the stability of the patient's functions (airway, breathing, circulation), the likelihood of an immediate life or organ threat, and the time frame in which a physician should see the patient (EMTALA medical screening begun)... 1. The Emergency Severity Index Triage instrument will be used to identify a triage class for all patients entering the emergency center at Spartanburg Regional Medical Center (SRMC)...VI. Triage Class II (Chest pain, acute respiratory, Behavioral Emergency, Code Stoke, etc) will be classed appropriately to include a brief triage assessment and then taken directly to appropriate clinical area. VII. Triage class III, IV, and V patients may be held in triage upon the completion of a triage assessment. Patients will be placed in the appropriate clinical area when available to assist with maximum patient flow through the emergency center."

Spartanburg Regional Healthcare System Policy, titled "Patient Elopement/AMA (Against Medical Advice)... Policy:.. Patients who are involuntarily committed, incompetent (including those with psychiatric disorders that make the patient a danger to themselves or to others), may be detained inside the health care facility against their will...2. Against Medical Advice: Notify the attending physician or designee immediately if a patient requests to leave the facility Against Medical Advice (AMA). Should a parent or guardian or a minor child wish to leave with the child Against Medical advice, notify the patients attending physician,case manager."

Spartanburg Regional Healthcare System Emergency Center BH (Behavioral Health) Admission Guidelines, titled, Admission Guidelines: EC (Emergency Center) Behavioral Health Unit. Policy: I. Generally, patients who are admitted to the Emergency Center Behavioral Health Unit (BHU) or WCBH (Women's Center Behavioral Health) are those patients who: 1) Have been medically cleared by the Emergency Center physician. 2) have been determined by the Emergency Center physician and/or the psychiatrist to require extended evaluation and/or treatment. 3) Cannot be immediately transferred to an appropriate facility for evaluation and treatment. II. Patients who are admitted to the Emergency Center Behavioral Unit must meet the following criteria as determined by the ED physician in consult with the psychiatrist/psychiatric liaison nurse and/or the EC clinical coordinator. 1.) Age >17 years. (patients <17 yoa (years of age) may be considered on a case by case basis). These patients <17 yoa will be separated from the adults with up to 3 patients in a room. 2) Limited Danger to others. .. 4.) Limited Medidcal History. 5.) EC and BH volumes may require re-evaluation and relocation of Adults and Adolescents BH patient in BH or WCBH. III. Patients admitted to the Emergency Center behavioral Health Unit are placed there temporarily until which time they can be admitted to the hospital, transferred to an appropriate facility or can be safely discharged home with an outpatient treatment plan. IV. Patients admitted to the Emergency Center Behavioral Health Unit remain Emergency Center patients. Procedure: ...1) Patients who are determined to be physiologically stable and have no emergency medical condition other than their behavioral health health problem will be referred to the psychiatry for evaluation. 3) The Emergency Center primary nurse may contact psychiatry for a consultation prior to the EC MD (Medical Doctor) medical screening examination for patients with history of treatment by a mental health professional, who present with complaints consistent with their past mental health history, and who are found by the EC primary nurse to be without physical complaints and physiologically stable.
2. A determination by the Psychiatrist in consultation with the EC physician that the patient requires evaluation and beyond the scope of an outpatient emergency visit can lead to the following disposition options:
1) the patient can be admitted in the SRMC Behavioral Health Program.
2) the patient can be transferred to an inpatient program outside of SRMC such as a (name) Psychiatric Hospital, etc.
3) The patient requires placement in the Emergency Center Behavioral Health Unit due to inability to place patient in the appropriate program. Placement in the Emergency Center Behavioral Health Unit is temporary until an appropriate bed is available in a inpatient program or the patient had been determined stable for discharge and outpatient treatment."
Further review of this policy revised 9/09 -Behavioral Health Center Pathway (Care Plan) indicated in part, Patient presents to triage nurse requests Psychiatric care, - Classified as urgent: Placed in Treatment areas as soon as possible EC RN assess patient Psych Liaison paged and evaluates patient in a timely manner based on acuity of condition. Primary RN relives Triage RN Classified as Emergent Completes patient assessment, Determines safety needs, Consults with Psych Liaison , and MD for Plan of Care, Identify least restrictive method to ensure safety: Primary RN stays with patient until plan of implemented... Implements standing orders: Collect Urine Sample for Urinary Drug Screen, Collects rainbow blood tubes and gold tube for Alcohol, Secretary to order Complete blood Count, Basic metabolic Profile...MD sees Patient. Psych Liaison consuls with MD Disposition determined Initiate transfer/admission documents, arranges transport if needed."


Patient #1
Record review conducted on 5/4/11 revealed Patient #1, a 15 year old female, seen in the Emergency Center on 4/22/11 at 10:08 a.m., with the chief complaint of SI/SA (suicidal ideation/suicidal attempt). Patient #1 was triaged ( evaluation to determine order of treatment) as a Class II (Behavioral Emergency) and vital signs were recorded as Temperature: 98.3; Blood Pressure: 116/71; Pulse: 103; and Respirations: 20. Assessment showed the patient had no pain and oxygen saturation level (a measure of how much oxygen the blood is carrying- Normal value 97% to 100 %) was 99%.

An entry into the patient's record (assessment sheet) on 4/22/11 at 1028 a.m. showed, "Parents bringing this pt (patient) to EC (emergency center) due to suspicions of suicidal ideation. Mother states that she found razor blades, pills, suicidal notes, and a possible noose. Per parents, pt (patient) started self mutilating approx.(approximately) 3 yrs (years) ago. Pt. states she took 16 Tylenol 500 mg (milligram) tablets last night. Pt noted to have a self inflicted laceration to the right inner arm. Pt noted to have multiple lacerations to the left arm, stating that she did those last week. Parents state that the pt has scarring on her shoulder and thighs from previous cutting. Pt states she gets picked on at school. Pt states that the problems started when her and her boyfriend broke up several years ago. Pt with little eye contact. Pt reluctant to answer questions. "

An entry by the nurse in the patient's record at 10:50 a.m. showed, "Response to treatment: respirations even and unlabored. note: pt mother informed that patient would be cleared medically and then referred to (Acute Care Hospital Name) Health System. Mother states that she would prefer to have medical clearance done at ( Acute Care Hospital Name) Hospital System as well. AMA (Against Medical Advice) signed by pt mother." Review of the Behavioral Emergency Pathway (Care plan) in patient #1's chart indicated the path to be followed was after the patient presented to triage and a request was made by the patient's mother for psychiatric care, the patient was classified as a behavior emergency and was to be placed in the treatment area as soon as possible and assessed by the EC RN and page the psych Liaison to evaluate the patient in a timely manner timely based on acuity of condition. The Primary nurse then relieves the triage nurse and the patient is classified as Emergent .... Consults with the Physician ... Primary Nurse stays with the patient until plan is implemented and the charge nurse is notified of assignment. Standing order for urine drug screen and blood drawn for laboratory test (ancillary services). The patient is seen by the physician. There was no evidence of documentation of a medical screening examination by the ED physician or a psychiatric evaluation by a physician in the patient's chart. The patient's family members reported that this patient had taken 16 Tylenol 500 mg tablets. There was no documentation that ancillary services were provided such as laboratory studies (blood work and urine drug screen) as indicated in the Behavioral Emergency Center pathway careplan, to assist with determining if an emergency medical condition exists. The facility staff also failed to follow the the e-mail directive dated 10/26/2010, as evidenced by failing to provide patient #1 with a medical screening examination as she presented with additional medical problems (i.e., overdose) along with behavioral problems. There was no documentation by a physician related to the risk and/or benefits of leaving the hospital against medical advice on the patient's chart. The patient's chart had a hospital form related to treatment received in the emergency department that was blank in the instructions area, referral area, and there were no signatures. In a small section labeled "Release from Responsibility for Discharge" located at the bottom of the form was the signature of the patient/designee dated 4/22/11. The section reads, "I certify that the patient named on this chart is being discharged against the advice of the attending physician and of the hospital administration. I acknowledge that I have been informed of the risks involved and hereby release the attending physician, his associates, and the hospital and any of its personnel from all responsibility for any ill effects which may result from such discharge." The nurse recorded on 4/22/11 at 10:51 a.m., "Acuity: Class 2(Behavior Emergency), mobility at discharge: ambulatory, condition: good, Note: pt alert and oriented x 3, vss (vital signs stable), answers questions approp, (appropriately) gait steady, left with parents." There was no documented evidence that patient #1 was taken directly to the appropriate area after being triaged as "Acuity: Class 2" a Behavioral Emergency, as stated in the facility's policy and procedure. There was also no documented evidence in the medical record to indicate that the attending physician or the case manager was notified immediately, as stated per the AMA policy that if the parent wanted to take the patient to (Acute Care Hospital Name) Health System after being told by EC the nurse that SRMC would clear the patient medically and then transfer her to (Hospital Name) Hospital system. Patient #1 ' s medical record from the (Acute Care Hospital Name) Health system revealed the patient was triaged as " Emergent/Serious ... Chief complaint: Behavioral/Mental issue to be evaluated.. Suicidal ideation ...hpi (history of present illness) - this am mom found 3 suicide notes, blades, bag of Tylenol and evidence of cutting on arm. Pt has hx(history) of similar issues but no hospitalizations. Went to Spartanburg Regional today, was triaged and apparently sent to (Acute Care Hospital Name) Hospital System without seeing a doctor." The physician documented "since mom found bag of Tylenol will screen for overdose after Tylenol level was resulted pt admitted to taking 16 500 mg tabs (tablets) last night after 9 p.m. Patient #1' s final diagnosis was " Suicidal ideation, Additional: Acetaminophen (Tylenol) overdose." Further review of the medical record indicated that patient #1 received an appropriate medical screening examination at (Acute Care Hospital Name) Health System, and was appropriately transferred to a psychiatric hospital for definitive care.

INTERVIEWS:

Staff Member #1
On 5/3/2011 at 1410, Staff Member #1 was interviewed in Emergency Department's registration area. Staff Member #1 reported that his/her Job duties included logging in patients that come in through the Emergency Room (ER) door on initial contact. During the interview, Staff member #1 reported, "Patients come through the door and the Representative finds out what the patient's chief complaint is. We put them in the system ASAP (As Soon As Possible). If it is a chest pain, the patient is immediately transferred via wheelchair within 10 minutes to the back. Sometimes the Representative has to go and assist the patient out of their vehicle to the wheelchair. Protocols are posted at the desk. We call the Triage nurse to get the patients back as soon as possible. The Triage nurse fills out the rest of the paperwork. " Staff Member #1 was asked about the Emergency Department's procedure for patients that are Behavioral Psychiatric patients less than 18 years old. Staff Member #1 replied, "We do not see patients in this ER for Behavioral Health if they are under 15 years old. The patient is stopped at the desk and usually the patient is not registered into the system. We, the representative and sometimes the triage nurse, will inform the patient and family member that the patient cannot be seen here. Usually someone from Behavioral Health will come and take the family/patient to a private area to let them know that they cannot be seen here. We stopped seeing adolescents this past January (2011). "
Staff Member #1 reported that he/she knew the process because he/she had been doing this job for the past 2 years.

Staff Member #2
On 5/3/2011 at 1315, Staff Member #2 was interviewed. Staff Member #2 verified that he/she was the Customer Relations Representative at the EMS (Emergency Medical Service) entrance into the Emergency Department. Staff Member #2 verified that he/she has direct contact with the EMS staff to direct to correct area when the patient is picked up in the field. Staff Member #2 explained the process for patients who arrive to the Emergency Department via EMS was, "EMS calls in to the desk when they have picked up someone and are on the way to the hospital. EMS notifies us of the chief complaint, who the patient is, and the type of treatments that have been started for the patient in the field. This information is hand written and then put into the computer when able. " When asked about the hospital's process for managing a patient who is less than 18 years old with behavioral health issues, Staff member #2 responded, "Behavioral Juveniles are not accepted here. EMS is notified at the door to take to (Acute Care Hospital) Hospital System. If medical treatment is needed, the hospital will treat the patient here and then send the patient to ((Acute Care Hospital) Hospital System. These patients are not entered into the hospital's system."

Emergency Department Medical Director
On 5/4/2011 at 9:45 a.m., the Emergency Department Medical Director was interviewed related to the process for admission of pediatric behavioral patients in the Emergency Department. The Medical Director reported, "They are administered a medical screening but there is no psychiatric program available here. There is no in patient care determined here. Typically, the hospital makes arrangements for them to go elsewhere. No psychiatrists are available here for adolescents. If EMS calls in with a psychiatric pediatric patient, they are diverted to another facility if they are 17 and under. One patient sat in the ER for 11 days without treatment and no one would take the patient for treatment. The patient was discharged to home with a referral to mental health. After this, we wanted to make sure patients were seen quickly, so will do a medical screen, but will not screen for psychiatric disorders. "

EMS Director
On 5/4/2011 at 10:15 a.m., the EMS Director was interviewed about the process for transporting pediatric behavior health patients to the Emergency Department of Spartanburg Regional Medical Center. The EMS Director reported, "If patients are less than 17 years old, they can not go to any hospitals in Spartanburg county. They go to (Acute Care Hospital) Hospital System. If they have medical problems, the patient will be stabilized but then sent to (Acute Care Hospital) Hospital System. A memo was sent out re: Pediatric patients that are behavioral health not going to SRMC."

Review of the e-mail (memo)dated 10/26/2010 at 10:36 A.M., from the Director of Emergency Medical Services, Transportation & Air Medical Services, reads, "Effective Immediately: There are no pediatric or adolescent psychiatric services available at Spartanburg County hospitals. If you have patient (age 17 or less) needing only psychiatric care, they need to be transported to (Hospital Name) Hospital System. Example being a patient who has threatened suicide or a behavioral issue. The patient's family should be advised that transport to (Hospital Name) Hospital System is required because the hospitals in Spartanburg no longer provide this service. If a patient has additional medical problems other than strictly behavioral (i.e. overdose, trauma), you must assess patient and determine if they are stable enough for the extended transport time (Hospital Name)Hospital System. Online medical control must be contacted if patient is transported to a Spartaanburg hospital. Please see your coordinator if there are any questions."

Staff Member #5
On 5/4/2011 at 2:25 p.m., Staff Member #5 who is a Registered Nurse with six (6) years employment on the Behavioral Health Unit reported, "My understanding is the hospital does not treat adolescents who present for psychiatric issues at our facility." The interview ended when the Registered Nurse was notified that a patient needed him/her.

Staff Member #6
On 5/4/2011 at 4:50 p.m., Staff Member #6 who is a Registered Nurse who works Triage, reported, "Triage nurse lets the nurse know what the patient is here for. If a patient is an adolescent for Behavioral Health, they are screened by the physician and sent to the correct area. " These patients cannot be placed in Behavioral Health area due to being unable to put a minor in that area due to safety issues. When asked for an age limit for the patients in the Behavioral health Unit, Staff Member #6 stated, "not sure. The physician dispositions patients to the correct area."

Staff Member #7
On 5/5/2011 at 9:35 a.m., Staff Member #7 who is a Patient Advocate in the ER Registration area was interviewed to assess the process for an adolescent with behavioral issues. When asked to describe the registration process for a patient who is less than 18 with a behavioral health issue who presents to the ER desk is, Staff member #7 reported, "We call Behavioral Health Unit and they come and talk with the patient/family. We do not put the patient in the system. The patient and family are taken to a private area and the triage or behavioral health staff talk with them. I do not know what the staff tells them. Sometimes, we call the triage nurse and the Triage Nurse will call the behavioral health nurse to see the patient and family and then the behavioral health nurse will take the patient and family into the consultation room. After the discussion , the patient and family leaves the hospital. The patient is not put in the system."

Staff Member #9
On 5/5/2011 at 12:10 p.m., Staff Member #9 (Hospital General Counsel) was interviewed about the hospital's processes when a behavioral health patient is brought to the emergency department. Staff Member #9 reported, "We have many issues regarding pediatric psychiatric patients. The Psychiatrist do not want to take care of these patients. All pediatric trauma goes to (Acute Care Hospital) Hospital System. We do not have pediatric trauma specialists here. The same is true for pediatric psychiatric patients. They also need to go to (Acute Care Hospital) Hospital System. If EMS shows up on the scene, they are directed to take these patients to (Acute Care Hospital) Hospital System because there is no one here to see these type patients. They want Spartanburg Regional hospital to take these patients."

Staff Member #10
On 5/5/2011 at 4:15 p.m., Employee #10, a Registered Nurse who performed Triage in the hospital's emergency department was interviewed to assess the hospital's processes for adolescent patients that present to the ER requesting for treatment for behavioral issues. Employee #10 reported, "When they (patients) come to the door of the emergency department, the patient's name was entered into the computer system. Patients are escorted to the triage nurse. Vital signs are taken and the chief complaint recorded. Patient's have a quick registration if they need to have immediate labs or X-rays. If patient's have psychiatric issues and are 15 or less, they are brought into an assigned room based on acuity. If the patient is an adolescent, they are seen by a physician and a registered nurse and an assessment is performed. All patients are treated the same regardless of age. "In the ER, we don't have a pediatric psychiatric nurse, but we treat all the same. Patient will get a screening that is the same for any diagnosis." We explore resources for the community to help them. In the behavioral unit, we only have senior adults and children are not placed there."

Staff Member #11
On 5/5/2011 at 4:30 p.m., Employee #11, a registered nurse who conducts Triage assessment in the hospital's Emergency Department was interviewed for processes related to pediatric adolescent patients that present to the hospital's ER for treatment. Employee #11 reported, "Vital signs are taken, question patient about problem, place patient in room, and give report to nurse for any diagnosis. May go to pediatric unit or women's unit if pediatric unit closed. Need a medical order for psychiatric liaison to see patient."

Staff Member #12
On 5/5/2011 at 9:45 a.m., an interview was conducted with Employee #12, a Customer Service Associate related to the hospital processes for pediatric patients that present to the Emergency Department for behavioral health issues. Staff Member #12 reported, "Get family/patient to fill out forms on desk. Call the Triage Nurse or Pediatric Nurse to let them know a pediatric patient is here. When I am here during the day, the patients always go through the triage process. " .

On the days of the EMTALA investigation based on interviews and review of medical records and policies and procedures and Physician credentialing files, the facility failed to ensure that patients presenting to the emergency department with identified behavioral emergencies received further medical examination and treatment that were within the capabilities of the ED to stabilize these individuals as required for 3 of 41 (#1, 39, and 40) medical records reviewed.

The findings are:

POLICY AND PROCEDURE:

The policy titled, "BH(behavioral Health) Admission Guidelines," Policy Number EC0002, specified in part, "Patients who are determined to have a physiological problem requiring further evaluation and/or treatment will be referred to psychiatry for evaluation until which time the physiological problem is stabilized or the Emergency Center physician determines that a psychiatric consultation is required during medical evaluation and treatment."

Credentialing Files- Physicians:
A review of the hospital's credentialing files revealed the hospital had four (4 )Board Certified General Psychiatrists on staff.


Patient #1
Record review conducted on 5/4/11 revealed Patient #1, a 15 year old female, seen in the Emergency Center on 4/22/11 at 10:08 a.m., with the chief complaint of SI/SA (suicidal ideation/suicidal attempt). Patient #1 was triaged ( evaluation to determine order of treatment) as a Class II (Behavioral Emergency) and vital signs were recorded as Temperature: 98.3; Blood Pressure: 116/71; Pulse: 103; and Respirations: 20. Assessment showed the patient had no pain and oxygen saturation level (a measure of how much oxygen the blood is carrying- Normal value 97% to 100 %) was 99%.

An entry into the patient's record (assessment sheet) on 4/22/11 at 1028 a.m. showed, "Parents bringing this pt (patient) to EC (emergency center) due to suspicions of suicidal ideation. Mother states that she found razor blades, pills, suicidal notes, and a possible noose. Per parents, pt (patient) started self mutilating approx.(approximately) 3 yrs (years) ago. Pt. states she took 16 Tylenol 500 mg (milligram) tablets last night. Pt noted to have a self inflicted laceration to the right inner arm. Pt noted to have multiple lacerations to the left arm, stating that she did those last week. Parents state that the pt has scarring on her shoulder and thighs from previous cutting. Pt states she gets picked on at school. Pt states that the problems started when her and her boyfriend broke up several years ago. Pt with little eye contact. Pt reluctant to answer questions. "

An entry by the nurse in the patient's record at 10:50 a.m. showed, "Response to treatment: respirations even and unlabored. note: pt mother informed that patient would be cleared medically and then referred to (Acute Care Hospital Name) Health System. Mother states that she would prefer to have medical clearance done at ( Acute Care Hospital Name) Hospital System as well. AMA (Against Medical Advice) signed by pt mother." Review of the Behavioral Emergency Pathway (Care plan) in patient #1's chart indicated the path to be followed was after the patient presented to triage and a request was made by the patient's mother for psychiatric care, the patient was classified as a behavior emergency and was to be placed in the treatment area as soon as possible and assessed by the EC RN and page the psych Liaison to evaluate the patient in a timely manner timely based on acuity of condition. The Primary nurse then relieves the triage nurse and the patient is classified as Emergent .... Consults with the Physician ... Primary Nurse stays with the patient until plan is implemented and the charge nurse is notified of assignment. Standing order for urine drug screen and blood drawn for laboratory test (ancillary services). The patient is seen by the physician. There was no documented evidence in the medical record to indicate that patient #1 with an identified Behavior Emergency and medical emergency (a reported overdose of Tylenol tablets) was provided stabilizing treatment as required on 4/22/11. Patient #1 ' s medical record from the (Acute Care Hospital Name) Health system revealed the patient was triaged as " Emergent/Serious ... Chief complaint: Behavioral/Mental issue to be evaluated.. Suicidal ideation ...hpi (history of present illness) - this am mom found 3 suicide notes, blades, bag of Tylenol and evidence of cutting on arm. Pt has hx(history) of similar issues but no hospitalizations. Went to Spartanburg Regional today, was triaged and apparently sent to (Acute Care Hospital Name) Hospital System without seeing a doctor." The physician documented "since mom found bag of Tylenol will screen for overdose after Tylenol level was resulted pt admitted to taking 16 500 mg tabs last night after 9 p.m. Patient #1' s final diagnosis was " Suicidal ideation, Additional: Acetaminophen (Tylenol) overdose." Further review of the medical record indicated that patient #1 received stabilizing treatment as required at this hospital.


Patient #39
Review of the EMS narrative report recorded by EMS on 10/21/10 at 8:27 p.m., revealed, "Responded to a mental subject with requested by ...Police. arrived on scene patient was being escorted to our unit by ...Police officer. Patient stated he wanted to kill himself because he didn't feel loved and wanted by his foster family, he is tired of getting bullied at school and felt really bad for stealing money from the school today. Patient also stated that he has smoked two dime bags of marijuana today about 5 hours prior to our arrival for the first time. This is not the patient's first attempt to harm himself. he stated he has several times in the past, and would have successfully done it tonight if no one had walked in on him in the bathroom. ....". Review of the EC Assessment Sheet indicated, the patient was triaged at 8:16 p.m. as a Class II (Behavioral Emergency) with a Chief Complaint: Suicidal. At 9:04 p.m., the registered nurse documented,"Pt presents to EC via EMS. The pt. states that he is here because he smoked weed for the first time today and it made him "go crazy".. he states that he locked himself in the bathroom and was "about to cut myself open" when his brother and grandmother picked the lock on the door and got him. Pt states that this is the third time he has had suicidal ideations and the second time he has attempted to act on these thoughts. he states he started feeling depressed today after smoking the marijuana. Grandmother (who is foster mother) reports that the pt has been emotionally disturbed and having serious behavior issues since having been in her care. She reports that the pt is experiencing emotional and physical abuse/neglect during childhood and he has threatened previous foster families with bodily harm. She states pt is a danger to himself and others at the home and she is afraid and uncomfortable having him in her care." At 9:09 p.m. The ED nurse documents : "Psychiatric Precautions: Adult Supervision, Close to Nursing Station." 9:10 p.m., the registered nurse documented,"Grandmother reports feeling uncomfortable and afraid of taking this pt back home. She states he is a danger to himself and others. ...." At 9:21 p.m., the registered nurse recorded,"Pt's caseworker has been contacted and is speaking with MD on the phone at this time." At 10:08 p.m., the emergency room physician recorded,"Appointment with Mental Health". At 10:49 p.m., the registered nurse documented,"Discharge Condition: Acuity 2 (Behavioral Emergency) Condition: Good, ambulatory, pt voiced understanding of plan of care, Follow up plan of care reviewed with pt, written dx instructions reviewed with person attend....". Documentation by the physician on the Emergency Physician Record- Psych, Disorder, Suicide attempt , Overdose sheet revealed in part, "found at home by the Police .. multiple sharp objects, weapons at home and backyard.. pt threatened to hurt someone or himself." ..ED course Foster mom uncomfortable taking pt home." Clinical Impression: Acute Agitation/Behavioral Problems." Review of the medical record indicated this patient was discharged with an Acuity level of 2 (behavioral emergency).The medical record lacked effective documentation to indicate that stabilizing treatment was provided, i.e., psychiatric evaluation and/or if this patient was no longer a threat to himself or others.

Patient #40

Patient #40 presented to the Emergency Department on 10/19/10 at 10: 47 p.m., via EMS transport. The EMS narrative report reads, "....16 yom (year old male) Pt. handcuffed sitting on couch at residence. Pt appeared emotionally distraught and trying to get out of handcuffs. County Officer on scene states Pt attempted to hang himself, His family members subdued him and handcuffed him themselves prior to County PSO arrival. Family states Pt was combative and tried to hang himself with a chain. Pt A (awake)/O (oriented) X4, ...On scene and on route, Pt uncooperative. ......Pt states he tried to hang himself twice today, First time with a rope that broke and second time with the chain and family stopped him. .......". At 10: 27 p.m., the Emergency Department registered nurse documented,"Chief Compliant: S/I tried to hang self" Triage Class II (Behavioral Emergency). At 10:50 p.m., the registered nurse recorded," pt present to EC via EMS after SI, attempt by hanging with chain. pt states that this week at school was being picked on by other students and told mother and father of incidents and pt states family "did not care" pt states that around 7:00 p.m., tried with a first attempt and pt states that rope broke. pt states 2nd attempt at around 10:00 p.m. with chain. pt states that father stopped the attempt pt states that thin rope was used and rope broke. pt states that he was in tree and when he jumped the limb broke along with the rope. pt states he was 2 - 3 ft in tree." At 11:15 p.m., the registered nurse wrote, "Dr....in to evaluate". At 11:35 p.m., the emergency room physician wrote, "appointment with Spartanburg Area Mental Health". The patient was discharged to home at 12:10 a.m.. There was no documentation that this class II (Behavioral Emergency ) patient #40 was provided further medical examination and treatment to stabilize his emergency psychiatric condition, as required to stabilize this patient who attempted to hang himself twice in one day.