HospitalInspections.org

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure the outpatient services to which the patient was referred was documented in the medical record and failed to ensure a list of area shelters was provided to one of one medical record reviewed (MR1) when discharged from the facility's Emergency Department (ED).

Findings include:

Review on July 9, 0215, of the facility's "Crisis Intervention Services in the Emergency Department" policy, last reviewed April 18, 2015, revealed "Purpose It is the policy of Pocono Health System to provide a Behavioral Health Crisis Intervention Service. This service will be provided during the hours of 0700-2300 on site and 2300-0700 on call coverage Monday through Friday. Weekend and holiday coverage is 1100-2300 on site and both 0700-1100 and 2300-0700 on call. The Crisis Intervention Specialist (CIS) will respond to ED physician orders for a Crisis evaluation and report findings to the ED physician and nurse and the psychiatrist on-call, as appropriate. Human Service Agencies will be made to provide an efficient, effective and respectful response to the needs of behavioral health patients and their families. Scope Crisis Intervention Specialist Guidelines 1. Crisis Intervention Specialist a. Conduct on-site consultation when indicated by ER physician. Complete detailed Suicide Risk Assessment. b. Complete CIS Consultation/Intake Form, using collateral information if patient unable to give coherent medical/psychiatric history. c. Contact psychiatrist on call to relay pertinent information Re: diagnostic impression and treatment recommendations. d. Make recommendations to ER physician. e. Document findings and recommended disposition. ... g. If out-patient or partial hospitalization services are indicated, make referral to appropriate agency."

Review on July 9, 2015, of MR2 revealed a family member completed a Mental Health Procedures Act of 1976 Section 302 paperwork. MR2 allegedly threatened to kill a family member and to burn the house down.

Review on July 9, 2015, of MR2 revealed psychiatrist documentation. The patient was evaluated by CF2. CF2 determined the patient's behavior did not support a mental health crisis. CF2 denied MR2's 302 commitment. Further review revealed CF2 documented the patient was not allowed to return to home.

Review on July 9, 2015, of MR2 revealed Crisis Intervention Specialist (CIS) documentation. EMP4 was aware of MR2's 302 denial, and the patient was not allowed to return to home. Further review revealed EMP4 documented MR2 was discharged from the ED with referral to outpatient services. There was no documentation in MR2 indicating what outpatient services were offered to the patient or that a list of area shelters was provided to the patient.

Review on July 9, 2015, of MR2 revealed nursing documentation. The patient was discharged to home.

Interview with EMP1 and EMP5 on July 9, 2015, at approximately 1:15 PM confirmed MR2's family member completed a Mental Health Procedures Act of 1976 Section 302 paperwork for allegedly threatening to kill a family member and to burn the house down; CF2 documented MR2's behavior did not support a mental health crisis and denied the 302 commitment. Further interview with EMP5 confirmed MR2 was discharged from the ED with referral to outpatient services and was not allowed to return to home. EMP5 confirmed there was no documentation indicating what outpatient services were offered or that a list of area shelters was provided to the patient.