HospitalInspections.org

Based on observation, interview and record review, the hospital failed to comply with CFR 489.24, the Emergency Medical Treatment and Labor Act (EMTALA) requirements when there was no evidence of:

a. The required qualifications of two labor and delivery nurses to perform the Medical Screening Exam (MSE) (Refer to A2406),
b. Ongoing reassessments, interventions and monitoring to ensure the Emergent Medical Condition (EMC) was stabilized prior to transfer (Refer to A2407), and
c. The requirements for an appropriate transfer being met. (Refer toA2409).

Findings:

a. Two of 44 nurses assigned to triage patients in labor and delivery had not completed the required class in Intermediate Fetal Monitoring. (A2406)
b. Seven of 20 sampled patients (Patients 1, 3, 5, 10, 12, 16, 20) who presented to the ED with psychiatric conditions including suicidal attempt, suicidal ideations or an altered level of consciousness were not provided ongoing reassessments and monitoring to ensure the condition did not deteriorate and the patient remained safe. (A2407)
c. Six of nine sampled patients (Patients 2, 3, 4, 5, 10, 20) transferred from the Emergency Department to acute psychiatric hospitals between 5/17/12 - 7/4/12 did not have evidence that the physician a) discussed the transfer with the patient, b) certified the patient was stable for transfer and that the benefits of the transfer outweighed the risks, and/or c) sent records related to the patient's medical condition to the receiving facility. (A2409)

Based on interview and record review, the facility failed to ensure all labor and delivery nurses assigned to triage patients had completed the required qualifications for performing the Medical Screening Exam (MSE).

Findings:

In review of a facility Standardized Procedure (SP) titled Medical Screening Exam Performed by the Labor & Delivery Triage Nurse, dated 5/29/12, page 3, there was stipulation "V. Training and Requirements: A. Labor and Delivery Registered Nurses who meet the following criteria may perform the procedure:" which included "4. Completion of the AWHONN (accrediting organization for Women's and Children's Health) Intermediate Fetal Monitoring (IFM) class or the equivalent.

In further review of this SP, pages 4-5, two licensed nurses (RN1, RN2) were noted on the list of nurses who were noted to have "met the requirements enabling them to perform Medical Screening Exams".

In review of a document titled MSE Training, dated July 2012, RN1 and RN2 were noted to be "sched" [scheduled] for an IFM class.

In an interview with the Labor & Delivery Interim Nurse Manager (INM) and the Nurse Educator (NE), they acknowledged RN1 and RN2 had a basic fetal monitoring class but had not as yet attended an IFM class. In a concurrent review of RN1 and RN2's personnel records there was evidence RN1 had completed a basic fetal monitoring class in February of 2007 and RN2 had completed basic fetal monitoring in September of 2009. The NM and NE acknowledged there was no further evidence that RN1 or RN2 had taken the AWHONN IFM class or any other class equivalent to the standard for intermediate fetal monitoring. The NE further acknowledged that there had been no AWHONN IFM class scheduled. The NE stated there had been no formal ongoing education for fetal monitoring as this was covered in annual competencies.

In review of RN1 and RN2's schedules, the following was noted:
a. RN1 had worked as a triage nurse on June 10, 14, 18, 22, 23, 26, 27 and July 2.
b. RN2 had worked as a triage nurse on June 14 and July 3.
Both nurses were assigned for scheduled work shifts in triage on the schedule beginning 7/8/12.

In an interview on 7/9/12 at 12:20 p.m. with the medical director of Labor and Delivery (MD1), she acknowledged she had not participated in any fetal monitor training or review with the labor and delivery nurses. MD1 stated "we have talked about it." [doing reviews of fetal monitor strips with the labor and delivery nurses].



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29821

Based on interviews and record review, the hospital failed to provide ongoing monitoring appropriate to the needs of 7 of 20 Sampled Patients (1,3,5,10,12,16 and 20) who had been triaged with emergent medical conditions, resulting in :
1) An elopement prior to the determination the emergent medication condition had been stabilized, and
2) The potential for undetected deterioration of the emergent conditions of other patients.

The failure to provide appropriate ongoing monitoring resulted in a threat to the safety of Patient 1 and the potential threat to other patients.

Findings:

The "Medical Screening Exam and Triage - Adult and Pediatric Policy," revised 6/8/12, defined the Emergency Department's (ED's) triage process, including five assigned patient Levels including the following:
"Level 1 patients (Resuscitation/Red) are unstable and require immediate life, limb or organ-saving interventions...
Level 2 patients (Emergent/Orange) These patients are at 1) high risk for deterioration, require time-sensitive treatments and/or have potential threats to life, limb or organs, and/or 2) have acute changes in level of consciousness, and/or 3) are in severe pain or distress based on patient complaint and clinical observations. These patients are high priority for care and room placement.
Level 3 patients (Urgent/Yellow) do not need immediate life-saving interventions...

Patients of higher level acuity (i.e. Level 2) should have reassessments and vital signs done, at a minimum, every two hours but more frequently when possible...

Patients assigned Level 3 acuity should have reassessments and vital signs done, at a minimum, every two hours...."

In addition, the "Emergency Department Structure Standards," revised 5/6/12, state, "Patients of the higher acuity levels, Level 2 (Orange) and Level 3 (Yellow), will be rechecked, at a minimum, every two hours...This recheck must include...a focused reassessment...."

The facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA), revised 6/25/12, stated, "The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred."

ED nurses and physicians were reminded in a 5/2/12 e-mail from the RN Performance Improvement Coordinator, "All psychiatric patients should have a focused nursing assessment completed at least every 2 hours...which includes relevant assessment criteria for this patient population."

Patient 1 was a 30 year-old brought to the ED on an involuntary hold by law enforcement at 12:05 a.m., 6/8/12 after having called the police department stating she "wanted to hang herself from the vent in [her] motel." Discharged from an inpatient psychiatric facility "a few months" before, Patient 1 had not been taking her antipsychotic medications (medications used to treat severe mental conditions) and was experiencing delusions (serious mental illness in which a person cannot tell what is real from what is imagined), paranoia (feelings of persecution) and auditory hallucinations (hearing things which weren't there). She described "feeling depressed" and was having "relationship difficulties" which included domestic violence, incarceration and her three-month old daughter being placed in protective custody at birth.

Patient 1 had a history of schizophrenia (a mental illness causing disturbed or unusual thinking, loss of interest in life, and/or strong or inappropriate emotions), alcohol abuse, depression and hospitalizations for prior suicide attempts.

1) Patient 1 was triaged as a Level 2 (emergent), placed in a hallway bed at 12:22 a.m. and later moved into a core ED bed at 1:43 a.m. A Crisis Services Licensed Clinical Social Worker (LCSW) described Patient 1 as having "impaired insight, impulse control and judgment" and continued the involuntary hold. Patient 1 was reassessed by her nursing caregiver at 2:11 a.m., had vital signs (blood pressure, pulse, respiratory rate, blood oxygen saturation measurement and temperature) taken at 4:11 a.m., and was reassessed at 6:48 a.m. and 7:03 a.m., when she was described by her RN as "anxious" and verbalizing "hopelessness." She was reassessed again at 7:28 a.m. Awaiting placement in an inpatient psychiatric facility, Patient 1 was moved from one ED care area to another at 8:02 a.m. She got up to use a bathroom located just outside the care area in which she had recently been placed. A staff member did not remain with Patient 1 while she was in the bathroom and she was noted to be missing at 8:24 a.m. She was never located.

2) Patient 3 was a 19 year-old brought to the ED by ambulance at 11:24 a.m., 5/22/12 with auditory hallucinations and a plan for suicide by "clawing [her] eyes out" after a family argument. She had been discharged from a mental health facility several months previously after a "psychological breakdown" but was no longer taking the medications with which she was sent home. She was assigned a Level 3 instead of a Level 2 in error, according to her triage nurse, and noted to be at high risk for suicide. Her psychological status was not reassessed until 3:28 p.m.

While she was subsequently awaiting placement in an inpatient psychiatric facility, there was an additional gap in reassessments between 5:45 a.m. - 10:07 a.m., 5.23/12. Patient 3 was transferred to an inpatient acute psychiatric hospital (APH) at 8:07 p.m., 5/23/12.

3) Patient 5 presented to the ED at 6:07 p.m., 5/3/12 after attempting to "cut his head off." Patient 5 had a history of schizophrenia, bipolar disorder and substance abuse "to help [him] with...suicidal tendencies." He had "no support system," was homeless and on parole after incarceration for molestation during a psychotic episode. Patient 5 was anxious and agitated, stating his "mom is talking to [him] from ashes" and "vampires are following [him] and [he] will hurt them." He was assessed to be at high risk for suicide and assigned a triage Level 2. Gaps in reassessment were noted between 7:47 p.m., 5/31/12 - 1:09 a.m., 6/1/12 and 1:09 a.m. - 11 a.m., 6/1/12. Patient 5 was transferred to an APH at 7:03 p.m., 6/1/12.

4) Patient 10 was an intoxicated 30 year-old brought in by ambulance at 5:55 p.m., 6/15/12 after attempting to cut his wrists. Patient 10 had a history of polysubstance abuse and depression with "3 - 4" previous suicide attempts; his last attempt was one week earlier for which he was hospitalized. He was triaged a Level 2 and evaluated by the Crisis Services LCSW. He felt "hopeless about his life getting better," support systems were inadequate and he could not afford medications for his depression. He was felt to be at moderate to high risk for suicide with impaired insight, judgment, decision-making capacity and impulse control, and placed on an involuntary psychiatric hold. Significant gaps in reassessments were noted between 8 a.m. - 12:50 p.m. and 12:52 p.m. - 4:41 p.m., 6/16/12 and 9:11 a.m. - 4:41 p.m., 6/18/12. Patient 10 was transferred to an APH at 6:58 p.m., 6/18/12.

5) Patient 12 was a 46 year-old brought in by ambulance at 5:56 p.m., 6/26/12 for a chief complaint of "sharp" chest wall pain, "active cardiac features." He had a history of human immunodeficiency virus (HIV). He was triaged a Level 3 but not reassessed until 9:25 p.m. He was moved from the hallway bed back into the waiting room at 10:14 p.m. He left without being seen by a physician before leaving without treatment at 11:36 p.m.

6) Patient 16 was a 21 year-old who presented to the ED at 8:21 p.m., 7/1/12 with anxiety, depression and plans "to overdose" or "jump in front of the light rail [train]" after being released from an inpatient psychiatric facility. The patient stated he had "no emotional support," felt "very alone" and "no longer [had] a home since his mother was evicted from his former home, where he was her primary caregiver." He had previously attempted suicide and an uncle and grandmother had taken their own lives. Patient 16 was assigned a suicide risk level of "moderately high" and triaged a Level 2. He was placed on an involuntary hold. While awaiting inpatient psychiatric facility admission, gaps in reassessments were noted between 2:57 a.m. - 6:31 a.m. and 6:04 p.m. - 10:26 p.m., 7/2/12. Patient 16 was transferred to an APH at 7:51 a.m., 7/3/12.

7) Patient 20, a 42 year-old with a history of bipolar disorder, depression and suicide attempts presented to the ED at 8:30 a.m., 7/2/12 with complaints of severe depression and suicidal ideation of one week. She had "several prior hospitalizations" for mental health care but had been "off medications" for 1-2 months. Patient 20 was triaged as a Level 2, evaluated by the Crisis Services LCSW and found to have "profound depression...worthlessness, hopelessness" and "significant anxiety." She was determined to be a "moderate to high suicide risk" and placed on an involuntary psychiatric hold at 1:45 p.m., 7/2/12. Gaps in reassessment were noted from 10:46 a.m. - 6:30 p.m., 7/2/12, from 8:27 p.m., 7/2/12 - 12:27 a.m., 7/3/12 and from 1:34 a.m. - 6:17 a.m., 7/3/12. Patient 20 was transferred to an APH at 12:10 a.m., 7/4/12.

A 4:44 p.m., 7/3/12 nursing note stated, "Patient up to use the restroom on her own." A 6:17 a.m., 7/3/12 entry read, "Patient self-showered." The medical record reflected no evidence that Patient 20 was accompanied by staff while on the involuntary hold.

The facility policy "Identification and Management of Patients at Risk for Suicide," revised 4/23/12, stipulates, "Patients will be placed in an appropriate, safe area where he/she can be directly observed by reliable caretaker or hospital personnel...Staff should make reasonable efforts to prevent elopement."

During an 11:21 a.m., 7/10/12 interview, AM1 confirmed, "Pts. are to be reassessed at least q [every] two hours if they are Level 2 or 3."

29821

Based on interview and record review for six of nine sampled patients (Patients 2, 3, 4, 5, 10, 20) transferred from the Emergency Department (ED) to acute psychiatric hospitals between 5/17/12 - 7/4/12, the hospital failed to provide evidence the physician:
a) Informed the patient of the reason, risks and benefits of transfer from the ED to an acute psychiatric hospital (APH), for four of nine sample patients (2, 3, 4, 10),
b) Certified that, based on information available at the time of transfer, the medical benefits of transfer outweighed the risks, for four of nine sample patients (3, 4, 5, 20), and/or
c) Sent patient records related to the medical condition to the receiving facility, for three of nine sample patients (2, 3, 10).

Findings:
The facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA), revised 6/25/12, stated, "Appropriate transfer occurs when ...
1b.The receiving facility...has agreed to accept transfer of the individual and to provide appropriate medical treatment.
1c. The transferring hospital...sends to the receiving hospital all medical records (or copies...) related to the emergency medical condition...and the informed written consent or certification required...
3b. For physician certification, the physician must sign a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from...treatment at another medical facility outweigh the increased risks to the individual...from being transferred...1) An express written certification is required...2) The certification must state the reason(s) for transfer..."

The "Emergency Department Structure Standards," revised 5/6/12, stated, "All patients being transferred out of the ED to other acute care facilities are transferred to the receiving facility with medical records related to the emergency condition...and a transfer document completed by a physician (Physician's Progress Record Transfer Statement to Acute Care Hospital)..."

ED nurses and physicians were reminded in a 5/2/12 e-mail from the RN Performance Improvement Coordinator, "All patients going to an inpatient psychiatric facility need to have transfer paperwork sent with them including the Transfer Statement form completed."

1) Patient 2, a 59 year-old, presented to the ED at 2:27 p.m., 5/16/12 after an intentional medication overdose intended to cause suicide. Patient 2 was determined to be at moderately high risk for suicide and assigned a triage Level 2 (Emergent). She was transferred to an APH at 11:59 p.m., 5/16/12. Patient 2's "Physician's Progress Record Transfer Statement to Acute Care Hospital" did not include the reason for transfer and evidence that pertinent medical records were sent to the receiving facility.

2) Patient 3, a 19 year-old, was brought to the ED by ambulance at 11:24 a.m., 5/22/12 with auditory hallucinations and a plan for suicide by "clawing [her] eyes out" after a family argument. She was noted to be at high risk for suicide and assigned a triage Level 3 (Urgent). Patient 3 was transferred to an APH at 8:07 p.m., 5/23/12. The "Physician's Progress Record Transfer Statement to Acute Care Hospital" form was not found in her medical record.

3) Patient 4, a 66 year-old, was brought to the ED by law enforcement on an involuntary psychiatric hold at 4:33 p.m., 5/30/12 for agitation, paranoia and homicidal ideation (a desire to kill others). He was assigned a triage Level 3. Patient 4 was evaluated, the involuntary hold continued and he was transferred to an APH at 1:44 p.m., 5/31/12. Patient 4's "Physician's Progress Record Transfer Statement to Acute Care Hospital" contained no evidence that the patient consented to the transfer or was unable to sign.

4) Patient 5, a 39 year-old, presented to the ED at 6:07 p.m., 5/3/12 after attempting to "cut his head off." He was anxious and agitated, stating his "mom is talking to [him] from ashes" and "vampires are following [him] and [he] will hurt them." He was assessed to be at high risk for suicide and assigned a triage Level 2. Patient 5 was transferred to an APH at 7:03 p.m., 6/1/12. His "Physician's Progress Record Transfer Statement to Acute Care Hospital" did not include acknowledgement of the physician certification statement.

5) Patient 10, a 30 year-old, was brought in by ambulance at 5:55 p.m., 6/15/12 after attempting to cut his wrists. He was triaged as a Level 2 and evaluated by the Crisis Services LCSW, who felt Patient 10 to be at moderate to high risk for suicide. He was placed on an involuntary psychiatric hold and transferred to an APH at 6:58 p.m., 6/18/12. Patient 10's "Physician's Progress Record Transfer Statement to Acute Care Hospital" did not include the reason for transfer and evidence that pertinent medical records were sent to the receiving facility.

6) Patient 20, a 42 year-old, presented to the ED at 8:30 a.m., 7/2/12 with complaints of severe depression and suicidal ideation (desire to kill oneself). Patient 20 determined to be a "moderate to high suicide risk" and placed on an involuntary psychiatric hold at 1:45 p.m., 7/2/12. Patient 20 was transferred to an APH at 12:10 a.m., 7/4/12. Her "Physician's Progress Record Transfer Statement to Acute Care Hospital" did not include acknowledgement of the certification statement.

During an 11:31 a.m., 7/10/12 interview, the physician Vice Chair, Clinical Operations (VCCO) reviewed the transfer forms, acknowledged some were incomplete or missing and stated, "We wouldn't find blanks acceptable". The VCCO acknowledged there was "room for improvement" in the completion of transfer forms.

According to the Plan of Correction from the previous EMTALA visit, "All patients being transferred out of the ED to other acute care facilities are now transferred to the receiving facility with...a transfer document completed by a physician." The monitoring plan included reviewing "a sample of ten records of patients who presented to the ED with complaints of a psychiatric condition each month for presence of a transfer summary." Quality improvement activity was not thorough as it did not commit to reviewing for the completeness of transfer documents.