HospitalInspections.org

Based on record review, interview with staff, and review of policy and procedures, the facility failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in that the facility failed to maintain/establish physician on-call list, failed to provide stabilizing treatment and failed to provide appropriate transfer.

See findings:

1) The Hospital failed to ensure an accurate list of on-call physicians is available. See A2404.

2) The Hospital failed to provide appropriate stabilizing treatment. See A2407.

3) The Hospital failed to ensure an appropriate transfer to a treatment hospital was completed. See A2409.

The cumulative effect of these failures creates an environment within the Emergency Department that could seriously endanger all patients seeking services.

Based on one of one on-call list of physicians provided by the facility for their Emergency Department, the hospital did not include a psychiatrist on the list.

Findings include:

Per request of the hospital, the on-call list of physicians for their Emergency Department for 04/10/2010, failed to reveal the name of the psychiatrist on-call. Under the heading of "Specialty Call" for a psychiatrist, the form reflects "psychiatrist on call".

No specific psychiatrist, with their contact information, is named or listed on the form.

Based on review of the medical record (Pt. #1), and one of one staff interview (A), the hospital failed to provide stabilizing treatment to a patient presenting with a major depressive illness.

Findings include:

Per review of the Pt #1's chart on 06/09/2010 at 3:30 PM, Pt. #1 arrived at Beloit Memorial's Emergency Department by ambulance with police escort on 04/10/2010 at 8:50 PM.

The patient was seen by hospital staff, evaluated, treated and discharged. Self-inflicted lacerations to the patient's neck and chest were sutured, a CT scan of the patient's head was done as a fall was suspected. Results of the CT scan were negative and his blood work was within normal limits.

Documentation by Dr. B (ED physician) at 11:24 PM on 04/10/10 indicates: "positive for depression, alcohol dependence, suicide gesture, suicidal ideation." The patient was discharged to police custody at 11:53 PM on 04/10/2010 with instructions on follow-up and wound care.

According to documentation noted in the medical record by RN C, at 10:34 PM on 04/10/10, ED staff was expecting the patient to ultimately be transported by police to a mental health hospital for emergency detention. Instead, according to a police report filed by Officer D (Police Department) at 5:16 PM on 04/11/2010, the patient was taken by the police to another facility (detox center) for detoxification at 11:53 PM on 04/10/2010.

The hospital treated the patient's presenting physical injuries, but there is no documentation the hospital made use of their on-call psychiatrist in an effort to stabilize the patient's major depressive illness.

The patient committed suicide three days after discharge. This was confirmed per interview with the hospital's Emergency Department Manager A on 06/10/2010 at 11:00 AM.

Based on review of the medical record (Pt. #1), and in one of one staff interviews (A), the hospital failed to transfer the patient to an appropriate facility.

Findings include:

Per review of the Pt. #1's chart on 06/09/2010 at 3:30 PM, Pt. #1 arrived at Beloit Memorial's Emergency Department by ambulance with police escort on 04/10/2010 at 8:50 PM.

The patient was seen by hospital staff, evaluated, treated and discharged. Self-inflicted lacerations to the patient's neck and chest were sutured, a CT scan of the patient's head was done as a fall was suspected. Results of the CT scan were negative and his blood work was within normal limits.

Documentation by Dr. B (ED physician) at 11:24 PM on 04/10/10 indicates: "positive for depression, alcohol dependence, suicide gesture, suicidal ideation." The patient was discharged to police custody at 11:53 PM on 04/10/2010 with instructions on follow-up and wound care.

According to documentation noted in the medical record by RN C, at 10:34 PM on 04/10/10, ED staff was expecting the patient to ultimately be transported by police to a mental health hospital for emergency detention. Instead, according to a police report filed by Officer D (Police Department) at 5:16 PM on 04/11/2010, the patient was taken by the police to another facility (detox center) for detoxification at 11:53 PM on 04/10/2010.

The hospital discharged Pt. #1 into police custody and not an appropriate hospital that could treat the patient's depressive mental illness. The patient committed suicide three days later. This was confirmed per interview with the hospital's Emergency Department Manager A on 06/10/2010 at 11:00 AM.