HospitalInspections.org

Based on review of the ED Central Log, ED medical record for patient #2, the BHU call log, the Nursing Home (A) notes and medical record for patient #2, Medical Staff Bylaws, Medical Staff Rules and Regulations, ED physicians' schedule, ED nurses' schedule, Medical Staff Roster, Weekend Call Schedule, credential files, personnel files, policies and procedures, tour, interviews, and an interview with the Sheriff Officer (#8), it was determined that the facility failed to provide an appropriate Medical Screening Examination, and Stabilizing Treatment, for one (1) of 20 sampled medical records when the patient (#2) arrived for a mental evaluation on 05/18/18.


Findings were:

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Examination;
Cross refer to A2407 as it relates to failure to provide Stabilizing Treatment; and

Based on observational tour of the emergency department, review of emergency department and nursing home medical records, facility policies and procedures, Medical Rules and Regulations, Medical Staff Bylaws, Emergency Department central logs, Senior Behavioral Health Unit call logs, Physician on-call schedules, Medical Staff Roster and hospital bed census report, Staff and county Sheriff Officer interviews it was determined the facility failed to provide an appropriate Medical Screening examination was provided within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled medical records when patient (#2) arrived to the emergency department with the Sheriff Officer under a 1013 for a mental health evaluation on 5/18/2018.

Findings were:
Observation

An observational tour of the Emergency Department (ED) was conducted with the Chief Nursing Officer (CNO #1) on 05/29/18 at 2:45 p.m. The CNO said that the medical screening examination in the ED was performed by a Physician or a mid-level (Nurse Practitioner or Physician's Assistant). The CNO further explained that the on-call schedule only covers weekends and includes a General Practitioner, a Family Medicine Practitioner who treats pediatrics, a Surgeon, a Certified Registered Nurse Anesthetist (on the surgical call schedule), the Psychiatrist, a mid-level provider to cover in-patients, a Pharmacist, and an on-call Administrator. The CNO went on to explain that the Medical Staff practitioners take call for their own patients during the week.

Emergency Department Log
Review of the ED Central Log revealed the patient (#2) presented to the ED on 05/18/18 at 6:29 p.m. for a mental evaluation.

Medical Record Review Pt. #2
Review of patient #2's emergency department medical record revealed the patient presented to the ED on 05/18/18 at 6:29 p.m. At 6:35 p.m. (times documented are electronic and not the time of the event), nurse #4 noted that the patient was alert and oriented to person, place, time, and situation. In addition, the nurse noted that the patient appeared to be in no acute (new onset) distress and that the patient ambulated to an ED room. The nurse noted that patient monitoring was in place, that the patient was ready for evaluation, and that the ED physician (#2) was notified. Nurse #4 noted that the Nursing Supervisor (#7) was notified that the patient had arrived in the ED from a nearby Nursing Home (A). RN #4 further noted that the Nursing Supervisor spoke with the Administrator at the Nursing Home (A) and was told that the patient had a bed assignment at another facility (B) on Monday 05/21/18 but that the Nursing Home (A) did not have the means to take care of the patient until the patient was transferred to the other facility (B). RN #4 noted that the Administrator of the Nursing Home (A) asked the Nursing Supervisor (#7) to have the ED physician evaluate the patient and to send the patient back to the Nursing Home (A) if needed.

The ED physician's (#2) note is 05/23/18 at 2:20 p.m., the physician noted that this was a late entry and that he/she saw the patient at 6:14 p.m. on 05/18/18 at the time the patient arrived in the ED and that he/she performed the triage assessment. The physician noted that the patient was in custody and that the Sheriff's Officer (#8) and the patient provided the patient's history. The physician noted that the patient was brought in on a 1013 (Georgia's legal form that allows a patient to be held involuntarily for up to 72 hours when the patient has been deemed to be a threat to self and/or others) from another institution (A). Review of the 1013 form revealed in part, "This is to certify that I have personally examined {[Patient #2}) on May 18, 2018 at 4:40 PM ...In my opinion this individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND A. .Presents a substantial risk and imminent harm to self and others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self and to other persons ...This individual: has committed/expressed recent overt acts/threats towards others ..." The 1013 was signed by an MD on 5/18/2018 at 5:11p.m. Patient #2 was to be admitted to the ED for observation until Monday when the patient was to be admitted to a behavioral health facility (B). The physician noted that the patient's chief complaint had started "yesterday". The physician noted that the patient had experienced a recent behavior change and had been angry and aggressive. The physician noted that the symptoms described were mild and that the patient had no injuries and denied suicidal thoughts, self-injurious thoughts, or hallucinations (seeing, hearing, smelling, tasting, or feeling something that is only in one's mind). The physician noted that review of the patient's systems was negative. In addition, the physician noted that he/she had reviewed and agreed with the nursing notes regarding the patient's chief complaint, history and physical information, past medical history, medications, and allergies. The physician noted that the patient's physical examination was normal, and that the patient was alert and oriented to person, place, and time. The physician noted that the patient's mood and thought process was normal, that the patient was pleasant to talk to and that the patient denied suicidal and/or homicidal thoughts. The physician noted that the patient was instructed to stay with a responsible adult family member or other responsible adult and to continue taking his/her (patient) medications as prescribed. The physician noted that the patient verbalized understanding of the discharge instructions. The physician noted that his/her impression was that the patient had anxiety reaction (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes) and that the patient was discharged back to the Nursing Home (A). There was no documented evidence of a mental health evaluation or any diagnostic blood tests or urinalysis being ordered to explain the change in patient #2's behavior.

At 7:07 p.m., RN #5 noted that the patient had no known allergies and was taking the following home medications:
Home meds listed:
--Amiodarone HCL (used to treat irregular heart rate) 200 milligrams (mg) by mouth one tablet a day;
--Aspirin (used to prevent blood clots) 325 mg by mouth one tablet a day;
--Donepezil HCL (used to treat mild to moderate dementia caused by Alzheimer's disease) 5 mg by mouth one tablet a day;
--Ferrous Sulfate (iron supplement) 325 mg one tablet by mouth once a day;
--Lexapro (used to treat anxiety) 5 mg one tablet by mouth once a day;
--Memantine HCL (used to treat dementia caused by Alzheimer's disease) 5 mg by mouth twice a day;
--Metoprolol Tartrate (used to treat high blood pressure) 25 mg, half a tablet by mouth twice a day;
--Multivitamin by mouth once a day;
--Seroquel (used to treat schizophrenia a mental disorder characterized by mistaken beliefs even when presented with evidence to the contrary, hallucinations [when someone sees, hears, taste, smells, or taste something that only exists in the person's mind], disorganized speech and behavior and bipolar disorder [mental disorder characterized by severe mood swings]) 25 mg one tablet by mouth a day; and
--Thiamine (vitamin) 100 mg by mouth a day.

At 7:09 p.m., the triage (assessment by a nurse to determine the order in which patients will be seen based on their signs and symptoms) Registered Nurse's (RN #4) notes indicated the patient arrived in the ED accompanied by a Sheriff's Officer. The nurse noted that the patient was sent to the ED from a local Nursing Home (A - where the patient resided) to be evaluated after the patient choked another resident. The nurse noted that the patient was in no acute distress. The triage nurse noted that the patient was there for a mental evaluation. The triage nurse noted that the patient had no known allergies and that the historian was the Nursing Home (A) records. The triage nurse further noted that the patient had received no treatment prior to arrival and that the patient's Glascow coma scale (evaluates a person's conscious state) was within normal limits. The nurse recorded the patient's temperature, pulse, respirations, and oxygen saturation as being within normal limits, and blood pressure as 96/61 (normal 120/70). The nurse noted that the patient had no pain. The triage nurse assigned the patient as a triage level four (4) priority.

At 7:12 p.m., nurse #4 noted that the patient's medical history included a history of psychiatric illness. The nurse further noted that the patient was assessed for self-harm and abuse and both assessments were negative. The nurse also noted that the patient's functional assessment was normal and that the patient had no impairments.

At 7:13 p.m., nurse #4 noted that the patient's condition was unchanged at the time of discharge, that discharge instructions were reviewed with the patient and that the patient had no learning barriers. The nurse noted that the patient was discharged to the Nursing Home (A) by the ED physician (#2) and that the patient walked out of the ED with the Sheriff's Officer (#8) who was to transport the patient back to the Nursing Home (A). The nurse noted that he/she called report to the Nursing Home (A).



Nursing Home A- Medical Record for patient #2

The Nursing Home's (A) Nurses' Notes, Social Progress Notes, and follow-up of the event was reviewed and revealed the following:
Nurses' Notes:
--On 05/8/18 at 2:30 p.m. and on 05/9/18 at 12:35 p.m., there was no documentation of any abnormal behavior.

--On 05/11/18 at 2:15 p.m., discussed behaviors with Director of Nurses, no behaviors since completing antibiotics for urinary tract infection. No documentation of abnormal behavior.

--05/18/18 1:50 p.m., called to patient's room and found patient (#2) had another patient in a headlock constricting the other patient's airway. Several staff members separated the patients. The patient (#2) was very agitated, hollering and states, "if he comes back in my room I'll kill him". Physician notified and orders noted. Social Worker and Administrator made aware.
--at 2:30 p.m., Haldol injection given for agitation in the right upper arm muscle (no documentation of amount administered).
--3:00 p.m., family made aware.
--4:30 p.m., Emergency Medical Services (EMS - ambulance) called to transport the patient but they refused and said patient needed to be made a 1013 because of liability. Administrator and physician notified and patient made a 1013.
--4:40 p.m., Police Officer arrived after EMS called the Sheriff's Office, staff explained that the patient needed to be transported to Emanuel Medical Center and Police Officer said the Sheriff's Office needed to transport the patient. A 1013 was signed at 4:40 p.m. by the physician at the Nursing Home (A) noting that the patient was a risk to self and/or others.
--5:10 p.m., Sheriff's Officer (#8) arrived to transport the patient on a 1013 which was signed by the Nursing Home (A) physician.
--5:20 p.m., family made aware.
--5:30 p.m., report called to ED nurse (#4) at Emanuel Medical Center.
--5:35 p.m., nurse at BHU said would not accept due to insurance even though 1013
--6:00 p.m., Social Worker attempting to find placement at a Behavioral Health Unit (BHU) and facility (B) has agreed to accept the patient on 05/21/18 if the patient still needs placement. Emanuel Medical Center will not accept the patient and another facility (C) has no beds.
--7:00 p.m., patient returned via Sheriff's Officer (#8). The patient is calm and follows commands and was placed on 1:1 continuous monitoring.
--Note by nurse with no time of when the note was written revealed the nurse had spoken with someone at Emanuel Medical Center after the Sheriff's Officer (#8) had left to transport the patient to Emanuel Medical Center and was told that the BHU could not accept the patient due to the patient's insurance. The nurse writing the note noted that he/she informed the hospital's staff member (#7) that the Nursing Home (A) physician wanted the patient seen in the ED and that the patient had acted out before when the patient had a urinary tract infection. The nurse writing the note indicated that he/she asked if the ED could do a urinalysis and that the hospital's nurse (#7) asked if the Nursing Home (A) could do a urinalysis and was told it would take few days to get the results back. The nurse writing this note indicated that the patient returned to the Nursing Home (A) at approximately 7:00 p.m.

--On 05/19/18, 05/20/18, 05/21/18, nurses' notes indicated the patient remained calm and cooperative. On 05/21/18 at 2:30 p.m., nurses' notes indicated the patient (#2) walked into the hall yelling at staff and shook the door trying to get out. Documentation revealed the patient was redirected to his/her room.
--9:00 a.m., called facility (B) and was told they would not accept the patient due to the patient's Medicaid still pending.

--On 05/22/18, nurses' notes indicated the patient was transferred to another Nursing Home facility (D).

Social Progress Notes:
--05/18/18 at 1:00 p.m., patient (#2) had an outburst of anger, was redirected and calmed by the Certified Nursing Assistant and nurse. Patient (#2) agreed to go to a behavioral health center.
--1:30 p.m., called facility (B) a local healthcare system regarding placement for the patient and was informed that the facility could not accept the patient but if the patient still needed placement on 05/21/18 the facility would be able to accept the patient. Called Emanuel Medical Center and spoke to a social worker and was advised that the social worker would have to talk with the Chief Executive Officer before the social worker could accept the patient and that he/she (Social Worker) would call back by 4:00 p.m. As of 4:30 p.m. no return call, called Emanuel Medical Center back and social worker had gone for the day.
--4:30 p.m., called BHU (C) and was told they could not accept the patient due to the patient's pending Medicaid.
--4:45 p.m., called EMS to transport the patient (#2), the Nursing Home (A) physician signed the 1013 and request that the patient be sent to the ED for evaluation regardless of whether the BHU "has accepted the patient or not". EMS refused to transport the patient, patient transported by a Sheriff's Officer.

The Nursing Home (A) follow-up dated 05/22/18 was documented by the Nursing Home's (A) Administrator. The Administrator noted that on 05/18/18 the staff were working on getting the patient accepted to facility (B) or facility (C). That both nearby facilities had declined to accept the patient based on the patient's insurance and/or staffing issues, and that Emanuel Medical Center was undecided. The Administrator noted that the Nursing Home (A) physician had made the patient a 1013 and wanted the patient evaluated in the ED. The Administrator noted that local EMS refused to transport the patient and that the local law enforcement agencies were notified. The Administrator noted that the Sheriff's Office reported that in the past they had provided transport as a courtesy but that they did not transport 1013s signed by a physician because a 1013 had to be signed by a judge. The Administrator noted that the Sheriff's Officer (#8) agreed to transport the patient as a courtesy and left to take the patient to Emanuel Medical Center. The Administrator noted that the hospital staff contacted the Nursing Home after the patient left and notified the Nursing Home (A) that the patient was not accepted and was informed that the patient was on the way and that the Nursing Home's (A) physician wanted ER to evaluate the patient. The Administrator noted that local law enforcement was upset and said they would no longer transport 1013s. The Administrator noted that he/she contacted a local magistrate judge who stated he/she (judge) would educate the law enforcement staff on 1013s signed by a physician. In addition, the Administrator noted that he/she called Emanuel Medical Center's Administrator but had not heard back from the Emanuel Medical Center Administrator as of 05/22/18. The Administrator noted that the patient (#2) had had no further outburst or inappropriate behavior and was being monitored 1:1.

On 05/29/19 the Nursing Home's (A) update of the 05/18/18 event was as follows:
Emanuel Medical Center's Administrator returned the Nursing Home's call on 05/24/18 and said that he/she would investigate the incident and suggested a meeting to prevent future problems. The ED Director called to apologize for any misunderstandings between the Nursing Home (A) facility and the ED and offered to fax the ED notes to the Nursing Home (A). SO reported ED staff said the Nursing Home had been informed that the patient had not been accepted. No labs or any tests performed.


Medical Staff Bylaws

Review of the facility's Medical Staff Bylaws, Reviewed and Approved: February 27, 2018, revealed under ARTICLE XIII, General Provisions
1. Rules and Regulations. Subject to the approval of the Board, the Executive Committee shall adopt such Rules and Regulations as may be necessary to implement these Bylaws. The Rules and Regulations shall relate to the proper conduct of Staff organizational activities and shall embody the level of practice required of each Staff appointee.


Medical Staff Rules and Regulations

Review of the facility's Medical Staff Rules and Regulations, Reviewed and Approved: February 27, 2018 with regard to EMERGENCY SERVICES revealed:
4. At least one (1) physician shall be immediately available for rendering emergency patient care 24 hours per day, seven days a week ... the physician will complete a relevant physical examination related to the injury or illness, description of significant clinical, laboratory and x-ray findings; diagnosis, including condition of patient; condition of patient on discharge or transfer; and final disposition, including instructions given to the patient/family, relative to necessary follow-up care.



Review of the facility's ED policies included but was not limited to the following:

I. Patients Requiring Psychiatric Evaluation, Policy Number 10.48, Origination Date: January 1994, Revised Date: May 2015, Reviewed and Approved Date: September 2017.
POLICY: Any patient accessing care at this facility who requires psychiatric treatment will be managed through referral and transferred to a psychiatric receiving facility and/or management through consultative psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer.
PROCEDURE: For Patients accessing the hospital through the Emergency Department:
1. The ED physician will evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:
a. All medical complaints shall be stabilized. Patient must be medically cleared prior to transfer to appropriate psychiatric facility.
2. Assessment and documentation shall include:
--Patient History
--Patient complaint
--Observation of signs and symptoms of mental, emotional, behavior or suspected substance abuse.
--Vital signs
--Documentation of potential danger to self, staff or others.

II. Emergency Medical Screening Exam for Low Acuity Patients in the Emergency Department, Policy Number 10.49, Origination Date: January 1994, Revised Date: May 2015. Reviewed and Approved Date: April 2017.
POLICY STATEMENT: It shall be the policy of facility to ensure appropriate screening is performed with all patients.
PURPOSE OF POLICY: To direct low acuity patients with non-urgent medical conditions to alternative community resources after the Medical Screen Exam (MSE) has been performed by a physician. The MSE must be appropriate to the individuals presenting signs and symptoms and the capability and capacity of the hospital.


III. Triage, Policy Number 10.42, Origination Date: January 1994, Revised Date: May 2015, Reviewed and Approved Date: September 2017.
POLICY STATEMENT: It shall be the policy of the facility to provide the best care for each individual patient that presents to the ED. PURPOSE OF POLICY: To promptly identify patients requiring immediate treatment of life threatening conditions and to prioritize according to acuity.
PROCEDURE:
1. The triage nurse will be an RN.
2. The triage nurse will prioritize each patient according to the clinical presentation and the nurse's clinical judgment. All patients will be brought back according to priority of need and not by time of arrival.

IV. Medical Classification of ED Patients, Policy Number 10.26, Origination Date: January 1994, Revised Date: May 2015, Reviewed and Approved Date: September 2017.
POLICY STATEMENT: It is the policy of the facility to assign a medical classification to all patients who present to the ED for medical treatment.
PROCEDURE:
Resuscitation (Level 1)
--Conditions that threaten life or limb. Aggressive interventions. Time to medical care IMMEDIATELY
Emergent (Level 2)
--Conditions that are a potential threat to life, limb or function requiring rapid medical intervention or delegated acts.
Time to medical care <15 min.
Urgent (Level 3)
--Often associated with significant discomfort and the inability to work or carry out activities or daily living. Patients may deteriorate and require emergency intervention. This level is most critical triage category for assessment, reassessment and reassignment. Time to medical care less than 30 min.
Less Urgent (Level 4)
--Conditions that may be related to patient's age or level of distress, with mild to moderate discomfort and that have a potential for deterioration or the development of complications. Time for medical care less than 60 min.
Non-Urgent (Level 5)
--Conditions that may be acute but non-urgent or may be part of a chronic problem. Time for medical care less than 120 min.

V. Reassessment of Emergency Department Patient, Policy Number 10.37, Origination Date: January 1994, Revised Date: May 2015, Reviewed and approved Date: September 2017.
PURPOSE OF POLICY: To provide guidelines for reassessment of patients
PROCEDURE:
4. Less-urgent and non-urgent patients will be reassessed every 1-2 hours.

DEFINITION OF EMERGENCY MEDICAL CONDITION: A medical condition manifesting itself by acute symptoms of severity (including sever pain) such that the absence of immediate medical attention could reasonably be expected to result in: ...
1. Placing the health of the individual (or, with respect to the pregnant woman or her unborn child) in serious jeopardy
PROCEDURE ...
--The hospital will provide a system of triage. .. .-The hospital and staff will treat presenting individuals to the full extent of the hospital's capabilities.
-
-The patient must have a medical screening exam using all services "Routinely available" to the emergency department to determine whether the patient has an emergency medical condition..
Emanuel Medical Center Senior Behavioral Health Unit Log
Review of the Behavioral Health Unit (SBHU) call log dated 05/18/18 revealed the BHU declined the patient (#2) at 5:03 p.m. because the patient would require 1:1 monitoring, census cap with staffing, and the patient's insurance.

Emanuel Medical Center Behavioral Health Bed Census Report
A review of the SBHU bed census report revealed the hospital's total bed capacity for the unit was 15. On 5/18/2018 the patient census for the unit was 13. The hospital's had the capability and capacity to provide the care for patient #2 when he presented to the with involuntary commitment papers for inpatient treatment.

Medical Staff Roster and Physician On-Call Schedule

Review of the facility's current Medical Staff Roster revealed the facility had one (1) physician listed as "Psychiatry". Review of the Weekend Call Schedule for 05/18/18 to 05/21/18 revealed the physician listed on the current Medical Staff Roster as "Psychiatry" was on-call when patient #2 presented to the hospital's emergency department with a 1013 on 5/18/2018 when a request was made by the Sheriff Officer for a mental health evaluation. A Psychiatrist was on call on 5/18/2018 when the patient presented to the ED, and was not called. The facility failed to ensure that ancillary service (i.e., Laboratory studies, radiology and on-call psychiatrist) routinely available in the ED were utilized to determine whether or not an emergency psychiatric condition existed for patient #2 on 5/18/2018, and despite the patient presenting to the hospital ED on a 1013.

Interviews


During an interview with ED physician (#2) on 05/30/18 at 10:00 a.m. in the Conference Room, the physician confirmed that he/she provided care for patient #2 on 05/18/18. The physician stated he/she did not receive a call from the Nursing Home or any paperwork regarding the patient (#2). Questioned as to the fact that his/her physician notes indicated that he/she had reviewed the nurses' notes, the physician replied that he/she had read every word of the nurses' notes. The physician said he/she did not try to contact the Nursing Home to obtain additional information about the patient. The physician further explained that patients arriving from the Nursing Home usually come with transfer paperwork but that this patient had none. The physician said he/she was not informed about what had happened at the Nursing Home or why the Nursing Home had transferred the patient. The physician said that a law enforcement officer (#8) arrived with the patient and reported that the patient was a 1013 from the Nursing Home. In addition, the physician said that the law enforcement officer reported that the patient was to be admitted to the ED and kept for three (3) days until the patient could be transferred to a facility that had agreed to accept the patient on Monday (05/21/18). The physician said that the patient was calm, cooperative and pleasant and had reported having an argument with another patient at the Nursing Home. The physician said that after talking to the patient and based on his assessment of the patient he/she did not think any diagnostic tests were necessary. The physician said he/she never saw the 1013 and was surprised that a law enforcement officer would bring a patient to the ED to be held for three (3) days when the patient had already been accepted by another facility.

During a telephone interview with RN (#7) on 05/30/18 at 10:45 a.m. in the Conference Room, the RN confirmed that he/she was the hospital's House Supervisor on Friday 05/18/18. The RN said he/she did not get a call from the Nursing Home regarding the patient being sent to the ED and never saw any transfer paperwork for the patient (#2). The nurse explained that on 05/18/18 he/she was making rounds in the ED and saw the patient and a Sheriff's Officer (8) standing at the nurses' desk. The RN said that he/she spoke with the ED nurse (#4) and was informed that the Nursing Home had sent the patient to be admitted to the Behavioral Health Unit (BHU) but that the BHU had informed the Nursing Home at 4:00 p.m. that the patient could not be accepted. The RN (#7) said the Sheriff's Officer didn't know why the patient had been sent to the facility if the BHU had declined the patient. RN #7 said he/she called the BHU and spoke with a nurse working on the BHU and informed that the BHU staff had informed the Nursing Home that the patient could not be accepted until Monday 05/21/18, because the precertification staff was not on duty for the weekend. The RN said that the BHU nurse reported that the Nursing Home staff were not happy because the Nursing Home wanted the patient to be sent over that day but the patient's insurance had not been approved so the BHU could not take the patient. The RN said he/she got the Nursing Home Administrator on-call's number and spoke with the nurse on duty. The RN said he/she asked, "What do we need to do for this patient" and "Why was the patient sent to be admitted to the BHU when the patient was not accepted?" RN #7 said that the Nursing Home nurse said he/she was following orders and that the patient was accepted by another facility and was to be transferred on Monday 05/21/18. The RN said that the Nursing Home nurse reported that the patient had had an altercation with another patient and that the Nursing Home didn't know what to do with the patient (#2). The RN said that he/she suggested placing the patient on a 1:1 (one staff member to one patient) monitoring until the patient was transferred and the Nursing Home nurse had agreed. RN #7 said that he/she asked for the Nursing Home Administrator's phone number but that when he/she called the Administrator there was no answer. The RN said that the Nursing Home nurse told him/her that the ED could do a urine test because sometimes the patient acted out when the patient's urine was off. The RN said that he/she asked the Nursing Home nurse if they could check patients' urine and was told yes that the Nursing Home used a urine dip stick. The RN stated he/she informed the ED nurse (#4) and the patient was seen and evaluated by the ED physician, discharged, and sent back to the Nursing Home.

During a telephone interview with RN (#4) on 05/30/18 at 8:00 p.m., the RN explained that he/she had been a RN for four (4) years and had worked in the ED for approximately 18 months. RN #4 said the Nursing Home (A) had called and reported that the patient (#2) had gotten physical with another patient and that the patient was being sent for a mental evaluation by the ED physician and then was to be admitted to the BHU. The RN said he/she hung up and called the BHU and was told that the patient had not been accepted to the BHU. The RN said a little later a Sheriff's Officer arrived with the patient (#2). The nurse said the officer informed had a copy of the 1013 and the Nursing Home (A) records. The nurse explained that normally a copy would be obtained for the facility but that he/she wasn't sure if anyone made a copy for the patient's chart. The nurse said the Sheriff's Officer informed him/her that the patient was to be held in the ED until Monday 05/21/18 until the patient could be sent to the other facility (B) because the Nursing Home (A) did not have any way of isolating the patient from other patients. The RN said he/she called the House Supervisor regarding the situation and that the House Supervisor called the Nursing Home (A) and was told that if the ED physician felt the patient was alright the patient was to return to the Nursing Home (A). The nurse said the ED physician went in to examine and talk with the patient and that the patient had remained calm and cooperative while in the ED. The RN said the patient had not acted up in the ED and had been pleasant when speaking with staff. The nurse said the patient had been discharged back to the ED and that the Sheriff's Officer took the 1013 back with the patient. In addition, the nurse explained that he/she had had to stay over that night to finish his/her charting because the ED had been very busy.

During a telephone interview with Sheriff's Officer #8 on 05/31/18 at 9:30 a.m., the Officer explained that on 05/18/18 he/she was driving when he/she received a call to go to the Nursing Home (A) and transport a 1013 patient (#2) to Emanuel Medical Center's ED. The Officer said that the local Police Department had refused to transport the patient and that the Sheriff's Department usually transports patients on a 1013 that has been signed by a judge. The Officer said that the Nursing Home (A) staff informed him/her that the patient was accepted to the facility's BHU. The Officer went on to say that the he/she was informed that the patient had mild Alzheimer's Disease and that he/she was familiar with Alzheimer's because his/her mother had Alzheimer's and was in a nursing home. The Officer explained the patient (#2) was alert and friendly. The Officer said that when he/she arrived it was supper time so he/she waited for the patient to finish eating before transporting the patient to the ED. The Officer said the patient never acted out enroute to the hospital, explaining that he/she and the patient talked and listened to

Based on review of medical records from the ED, and from Nursing Home A for patient #2, the BHU call log, policy and procedure, Bed census report, Medical Staff Roster, Weekend On-call Schedules and interviews with the staff and the County Sheriff Officer it was determined that the facility failed to provide Stabilizing Treatment for one (1) of 20 sampled medical records (#2) when the patient arrived for a mental evaluation on 05/18/18.



Findings were:


Policy and Procedure

I. Patients Requiring Psychiatric Evaluation, Policy Number 10.48, Origination Date: January 1994, Revised Date: May 2015, Reviewed and Approved Date: September 2017.
POLICY: Any patient accessing care at this facility who requires psychiatric treatment will be managed through referral and transferred to a psychiatric receiving facility and/or management through consultative psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer.
PROCEDURE: For Patients accessing the hospital through the Emergency Department:
1. The ED physician will evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:
a. All medical complaints shall be stabilized. Patient must be medically cleared prior to transfer to appropriate psychiatric facility.
2. Assessment and documentation shall include:
--Patient History
--Patient complaint
--Observation of signs and symptoms of mental, emotional, behavior or suspected substance abuse.
--Vital signs
--Documentation of potential danger to self, staff or others.


Medical Record Review Pt. #2
Review of patient #2's emergency department medical record revealed the patient presented to the ED on 05/18/18 at 6:29 p.m. At 6:35 p.m. (times documented are electronic and not the time of the event), nurse #4 noted that the patient was alert and oriented to person, place, time, and situation. In addition, the nurse noted that the patient appeared to be in no acute (new onset) distress and that the patient ambulated to an ED room. The nurse noted that patient monitoring was in place, that the patient was ready for evaluation, and that the ED physician (#2) was notified. Nurse #4 noted that the Nursing Supervisor (#7) was notified that the patient had arrived in the ED from a nearby Nursing Home (A). RN #4 further noted that the Nursing Supervisor spoke with the Administrator at the Nursing Home (A) and was told that the patient had a bed assignment at another facility (B) on Monday 05/21/18 but that the Nursing Home (A) did not have the means to take care of the patient until the patient was transferred to the other facility (B). RN #4 noted that the Administrator of the Nursing Home (A) asked the Nursing Supervisor (#7) to have the ED physician evaluate the patient and to send the patient back to the Nursing Home (A) if needed.

The ED physician's (#2) note is 05/23/18 at 2:20 p.m., the physician noted that this was a late entry and that he/she saw the patient at 6:14 p.m. on 05/18/18 at the time the patient arrived in the ED and that he/she performed the triage assessment. The physician noted that the patient was in custody and that the Sheriff's Officer (#8) and the patient provided the patient's history. The physician noted that the patient was brought in on a 1013 (Georgia's legal form that allows a patient to be held involuntarily for up to 72 hours when the patient has been deemed to be a threat to self and/or others) from another institution (A). Review of the 1013 form revealed in part, "This is to certify that I have personally examined {[Patient #2}) on May 18, 2018 at 4:40 PM ...In my opinion this individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND A. .Presents a substantial risk and imminent harm to self and others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self and to other persons ...This individual: has committed/expressed recent overt acts/threats towards others ..." The 1013 was signed by an MD on 5/18/2018 at 5:11p.m. Patient #2 was to be admitted to the ED for observation until Monday when the patient was to be admitted to a behavioral health facility (B). The physician noted that the patient's chief complaint had started "yesterday". The physician noted that the patient had experienced a recent behavior change and had been angry and aggressive. The physician noted that the symptoms described were mild and that the patient had no injuries and denied suicidal thoughts, self-injurious thoughts, or hallucinations (seeing, hearing, smelling, tasting, or feeling something that is only in one's mind). The physician noted that review of the patient's systems was negative. In addition, the physician noted that he/she had reviewed and agreed with the nursing notes regarding the patient's chief complaint, history and physical information, past medical history, medications, and allergies. The physician noted that the patient's physical examination was normal, and that the patient was alert and oriented to person, place, and time. The physician noted that the patient's mood and thought process was normal, that the patient was pleasant to talk to and that the patient denied suicidal and/or homicidal thoughts. The physician noted that the patient was instructed to stay with a responsible adult family member or other responsible adult and to continue taking his/her (patient) medications as prescribed. The physician noted that the patient verbalized understanding of the discharge instructions. The physician noted that his/her impression was that the patient had anxiety reaction (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes) and that the patient was discharged back to the Nursing Home (A). There was no documented evidence of a mental health evaluation or any diagnostic blood tests or urinalysis being ordered to explain the change in patient #2's behavior.


Nursing Home A- Medical Record Review

The Nursing Home (A) follow-up dated 05/22/18 was documented by the Nursing Home's (A) Administrator. The Administrator noted that on 05/18/18 the staff were working on getting the patient accepted to facility (B) or facility (C). That both nearby facilities had declined to accept the patient based on the patient's insurance and/or staffing issues, and that Emanuel Medical Center was undecided. The Administrator noted that the Nursing Home (A) physician had made the patient a 1013 and wanted the patient evaluated in the ED. The Administrator noted that local EMS refused to transport the patient and that the local law enforcement agencies were notified. The Administrator noted that the Sheriff's Office reported that in the past they had provided transport as a courtesy but that they did not transport 1013's signed by a physician because a 1013 had to be signed by a judge. The Administrator noted that the Sheriff's Officer (#8) agreed to transport the patient as a courtesy and left to take the patient to Emanuel Medical Center. The Administrator noted that the hospital staff contacted the Nursing Home after the patient left and notified the Nursing Home (A) that the patient was not accepted and was informed that the patient was on the way and that the Nursing Home's (A) physician wanted ER to evaluate the patient. The Administrator noted that local law enforcement was upset and said they would no longer transport 1013's. The Administrator noted that he/she contacted a local magistrate judge who stated he/she (judge) would educate the law enforcement staff on 1013's signed by a physician. In addition, the Administrator noted that he/she called Emanuel Medical Center's Administrator but had not heard back from the Emanuel Medical Center Administrator as of 05/22/18. The Administrator noted that the patient (#2) had had no further outburst or inappropriate behavior and was being monitored 1:1.

On 05/29/19 the Nursing Home's (A) update of the 05/18/18 event was as follows:
Emanuel Medical Center's Administrator returned the Nursing Home's call on 05/24/18 and said that he/she would investigate the incident and suggested a meeting to prevent future problems. The ED Director called to apologize for any misunderstandings between the Nursing Home (A) facility and the ED and offered to fax the ED notes to the Nursing Home (A). SO reported ED staff said the Nursing Home had been informed that the patient had not been accepted. No labs or any tests performed.


Medical Staff Roster and Physician On-Call Schedule

Review of the facility's current Medical Staff Roster revealed the facility had one (1) physician listed as "Psychiatry". Review of the Weekend Call Schedule verified that on 05/18/18 the physician listed on the current Medical Staff Roster as "Psychiatry" was on-call when patient #2 presented to the hospital's emergency department under a 1013 on 5/18/2018 when a request was made by the Sheriff Officer for a mental health evaluation.

Emanuel Medical Center Senior Behavioral Health Bed Census Report
A review of the SBHU bed census report revealed the hospital's total bed capacity for the unit was 15. On 5/18/2018 the patient census for the unit was 13
Patient #2 was brought to the ED on 5/18/2018 under a 1013 by a Sheriff Officer for a mental health evaluation. The patient was discharged from the ED on 5/18/2018 without addressing the 1013 (Involuntary Commitment) for a mental health evaluation, and as stated in the 1013 the patient expressed threats towards others in Nursing Home A. Patient #2 was not stable at the time of discharge on 5/18/2018. A psychiatrist was on call but was not consulted.

Interviews
During an interview with ED physician (#2) on 05/30/18 at 10:00 a.m. in the Conference Room, the physician confirmed that he/she provided care for patient #2 on 05/18/18. The physician said he/she never saw the 1013 and was surprised that a law enforcement officer would bring a patient to the ED to be held for three (3) days when the patient had already been accepted by another facility.


Supervisor called the Nursing Home (A) and was told that if the ED physician felt the patient was alright the patient was to return to the Nursing Home (A). The nurse said the patient had been discharged back to the ED and that the Sheriff's Officer took the 1013 back with the patient. In addition, the nurse explained that he/she had had to stay over that night to finish his/her charting because the ED had been very busy.


During a telephone interview with Sheriff's Officer #8 on 05/31/18 at 9:30 a.m., the Officer explained that on 05/18/18 he/she was driving when he/she received a call to go The Officer said that the physician's order from the Nursing Home (A) was to take the patient to the ED for evaluation and then the patient was to go to the facility's BHU.