HospitalInspections.org

Based on staff interview, review of facility policy and procedure, and review of the facility on-call physician lists, it was determined the facility failed to ensure that individual names of physicians are identified on the Emergency Department's on-call list, for all disciplines.

Findings include:

Reference: Facility policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)" states, " ... On-Call Physicians ... a list of physicians who are on-call to come to or provide telehealth to its emergency departments in order to provide the consultation or treatment necessary to stabilize a patient with an emergency medical condition. ..."

1. On 4/14/21, at the Stratford location, a review of the Emergency Department's physician's on-call schedule for "Airway" revealed that a group name was listed, instead of an individual physician name, on the following dates:

a. On November 2020: 11/3, 11/6, 11/7, 11/8, and 11/16.

b. On December 2020: 12/7, 12/9, 12/25, 12/26, and 12/27.

c. On January 2021: 1/4, 1/11, 1/21, and 1/25.

d. On March 2021: 3/29

2. The above findings were confirmed with Staff #ST3.


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3. On 4/19/21, at the Cherry Hill location, a review of the Emergency Department's physician's on-call schedule for "Airway" revealed that a group name was listed, instead of an individual physician name, on the following dates:

a. On January 2021: 1/4, 1/11, 1/21, and 1/25.

4. The above findings were confirmed with Staff #CH15.

Stratford Campus

A. Based on a review of two (2) of eight (8) Medical Records (#ST1 and #ST18) of patients receiving Behavioral Health Evaluations in the Emergency Department (ED), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure that all behavioral health assessments are documented in the medical record when determining if an emergency medical condition is stabilized in a psychiatric patient.

Findings include:

Reference: Facility policy titled, "Management of the Mental/Behavioral Health Patient in the Emergency Department" states, " ...Procedure: ...4. If the Behavioral Health Liaison is consulted by the ED provider, he/she assesses the patient for mental health care needs and disposition. ...Behavioral Health Liaison will document key elements in the patient's medical record including, but not limited to, pertinent assessment findings, recommended interventions, and disposition. ..."

1. On 4/16/21 at 10:00 AM, a review of Medical Record #ST1 revealed the following:

a. On 9/22/20 at 2:01 PM, Patient #ST1 arrived in the ED with the police department and EMS (Emergency Medical Services) from a hotel where he/she was found screaming and a chief complaint of "psychiatric evaluation."

(i) At 2:11 PM, Staff #ST34, an ED Physician, initiated the MSE (Medical Screening Exam) and at 3:13 PM he/she wrote an order clearing the patient medically for a behavioral health consult.

(ii) Review of the ED Provider Note by Staff #ST34 stated, "...Patient seen and evaluated by behavioral health [name]; clear for discharge with follow-up with EISS (Early Intervention Support Services)..."

(iii) At 3:25 PM, Patient #ST1 was discharged home.

b. Upon review, there was no documentation in the medical record of a Behavioral Health Evaluation, including pertinent assessment findings, recommended interventions, and disposition, as indicated in the facility policy.

2. On 4/16/21 at 11:15 AM, a review of Medical Record #ST18 revealed the following:

a. On 3/22/21 at 7:48 AM, Patient #ST18 arrived in the ED stating he/she "feels suicidal" and a chief complaint of "psychiatric evaluation."

(i) At 7:57 AM, Staff #ST35, an ED Physician, initiated the MSE (Medical Screening Exam) and at 9:04 AM, he/she wrote an order clearing the patient medically for a behavioral health consult.

(ii) Review of ED Provider Note by Staff #ST35 stated, "Patient was seen and evaluated by behavioral health specialist ... Per Behavioral Health patient stable for discharge with outpatient follow-up..."

(ii) At 11:32 AM, Patient #ST18 was discharged home.

b. Upon review, there was no documentation in the medical record of a Behavioral Health Evaluation, including pertinent assessment findings, recommended interventions, and disposition, as indicated in the facility policy.

3. The above findings were confirmed during the exit conference with Staff #ST1, Staff #ST2, Staff #ST3, and Staff #ST23.



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Cherry Hill Campus

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined the facility failed to ensure that all behavioral health assessments are documented in the medical record when determining if an emergency medical condition is stabilized in a psychiatric patient.

Findings include:

Reference: Facility policy titled, "Management of the Mental/Behavioral Health Patient in the Emergency Department" states, " ...The County Crisis Screener evaluates the referred BH [behavioral health] patient based on the designated screening center process... -Screener will document key elements in the patient's medical record including, but not limited to, pertinent assessment findings, recommended interventions, and disposition... ."

1. On 4/20/2021, a review of Medical Record #CH4 revealed the following:

a. On 12/24/2020 at 2:06 AM, Patient #CH4 arrived in the Emergency Department (ED) with a complaint of suicidal ideation (SI) and a plan to commit suicide by overdosing on pills.

(i) At 2:08 AM, Staff #CH29, an ED physician, documented in the ED Course that the patient "feels safe now that [the patient] knows [the patient]'s getting help." Staff #CH29, after initiating the MSE, wrote an order clearing the patient medically for a behavioral health consult.

(ii) Review of the medical record revealed a behavioral health assessment by a crisis screener.
At 4:10 AM, the crisis screener documented on an "ED Crisis Patient Screening Summary" form a summary of the Screening Findings, Plan of Care, and that the case was reviewed with the physician (Staff #CH29).

2. Review of Medical Record #CH4 revealed no documentation of the complete notes by the crisis screener, summarized on the "ED Crisis Patient Screening Summary."

a. Upon interview, Staff #CH16 identified that the crisis screener's notes are not part of the medical record.

b. Upon request to Staff #CH16, the complete crisis screening notes were obtained and reviewed. Two progress notes and a discharge note were identified, including a progress note that stated, "...PT (patient) denied current SI [the patient stated] that [the patient] feels safe in the hospital but that it could all change when [the patient] gets home and could possibly make an attempt to harm [the patient]. Pt is requesting discharge..."

c. Upon interview, Staff #CH16 confirmed that the "ED Crisis Patient Screening Summary" did not give an accurate description of the crisis assessment of the patient.

(i) Staff #CH16 reconfirmed that the ED physician does not have access to the complete crisis screening notes at the time of care of the patient.

(ii) The medical record lacked evidence of the content of the discussion between the crisis screener and the ED physician before the patient was discharged, including pertinent assessment findings.

3. The "CRISIS INTERVENTION SAFETY PLAN/DIS[title cut off by patient label]," included in both the medical record and the crisis screening notes, was signed by the crisis screener but was not signed by the patient or the patient's legal authorized representative and was not witnessed.

4. The above findings were confirmed with Staff #CH16.

Stratford Campus

A. Based on a review of two (2) of eight (8) Medical Records (#ST1 and #ST18) of patients receiving Behavioral Health Evaluations in the Emergency Department (ED), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure that all behavioral health assessments are documented in the medical record when determining if an emergency medical condition is stabilized in a psychiatric patient.

Findings include:

Reference: Facility policy titled, "Management of the Mental/Behavioral Health Patient in the Emergency Department" states, " ...Procedure: ...4. If the Behavioral Health Liaison is consulted by the ED provider, he/she assesses the patient for mental health care needs and disposition. ...Behavioral Health Liaison will document key elements in the patient's medical record including, but not limited to, pertinent assessment findings, recommended interventions, and disposition. ..."

1. On 4/16/21 at 10:00 AM, a review of Medical Record #ST1 revealed the following:

a. On 9/22/20 at 2:01 PM, Patient #ST1 arrived in the ED with the police department and EMS (Emergency Medical Services) from a hotel where he/she was found screaming.

(i) At 3:13 PM, Staff #34, an ED physician, wrote an order stating that the patient was "Medically Cleared for Behavioral Health Evaluation."

(ii) Review of the ED Provider Note by Staff #ST34 stated, "...Patient seen and evaluated by behavioral health [name]; clear for discharge with follow-up with EISS (Early Intervention Support Services)..."

(iii) At 3:25 PM, Patient #ST1 was discharged home.

b. Upon review, there was no documentation in the medical record of a Behavioral Health Evaluation, including pertinent assessment findings, recommended interventions, and disposition, as indicated in the facility policy.

2. On 4/16/21 at 11:15 AM, a review of Medical Record #ST18 revealed the following:

a. On 3/22/21 at 7:48 AM, Patient #ST18 arrived in the ED stating he/she "feels suicidal."

(i) At 9:04 AM, Staff #ST35, an ED physician, wrote an order stating that the patient was "Medically Cleared for Behavioral Health Evaluation."

(ii) Review of ED Provider Note by Staff #ST35 stated, "Patient was seen and evaluated by behavioral health specialist ... Per Behavioral Health patient stable for discharge with outpatient follow-up..."

(ii) At 11:32 AM, Patient #ST18 was discharged home.

b. There was no documentation in the Medical Record, of a Behavioral Health Evaluation, including pertinent assessment findings, recommended interventions, and disposition, as indicated in the facility policy.

3. The above findings were confirmed during the exit conference with Staff #ST1, Staff #ST2, Staff #ST3, and Staff #ST23.




38289

Cherry Hill Campus

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined the facility failed to ensure that all behavioral health assessments are documented in the medical record when determining if an emergency medical condition is stabilized in a psychiatric patient.

Findings include:

Reference: Facility policy titled, "Management of the Mental/Behavioral Health Patient in the Emergency Department" states, " ...The County Crisis Screener evaluates the referred BH [behavioral health] patient based on the designated screening center process... -Screener will document key elements in the patient's medical record including, but not limited to, pertinent assessment findings, recommended interventions, and disposition... ."

1. On 4/20/2021, a review of Medical Record #CH4 revealed the following:

a. On 12/24/2020 at 2:06 AM, Patient #CH4 arrived in the Emergency Department (ED) with a complaint of suicidal ideation (SI) and a plan to commit suicide by overdosing on pills.

(i) At 2:08 AM, Staff #CH29, an ED physician, documented in the ED Course that the patient "feels safe now that [the patient] knows [the patient]'s getting help ...." and wrote an order at 2:42 AM stating, "Medically Cleared for Crisis Outreach."

b. At 4:10 AM, the crisis screener documented the following, on the "ED CRISIS PATIENT SCREENING SUMMARY":

(i) "SCREENING FINDINGS" section: "Pt (patient) is a 16y.o (year old) male-presented to crisis for reports of SI with plan to OD (overdose) by pills. Pt denied current SI/HI, [illegible writing]. Pt d/c (discharged) w/ (with) referrals."

(ii) "PLAN OF CARE" section: "Return to the Community" was checked off, and "Case reviewed with [named physician, Staff #CH29]."

2. An interview with Staff #CH16 identified that the crisis screener's notes are not part of the medical record.

3. Upon request to Staff #CH16, the crisis screening notes were obtained and reviewed. The following was identified:

a. A progress note that stated "Assessment ...[Patient] stated that [the patient] was last in the hospital back on May/June 2020 for PTSD (post-traumatic stress disorder). PT (patient) stated that (the patient) was sexually assaulted in 2019. PT reported that [the patient] doesn't eat or sleep. PT stated that [the patient] has a dx (diagnosis) of Depression, anxiety, and PTSD. [The patient] stated that [the patient] is on medications ... PT reported a hx (history) of multiple suicidal attempts ... PT denied current SI [the patient stated] that [the patient] feels safe in the hospital but that it could all change when [the patient] gets home and could possibly make an attempt to harm [the patient]. Pt is requesting discharge ..."

b. A second progress note that stated, "Collateral visit with ...(mother) ... Mom reported that the PT called the national suicide hotline ... Mom stated that she doesn't know what PT said but the cops came knocking at her door saying that she needed to bring the PT to crisis. Mom stated that before hers on [sic] told her that [the patient] was having suicidal thoughts but she told [the patient] that [the patient] did not need to come to the hospital ... She stated that [the patient] will actually make suicide attempt but to get someone's attention not to actually harm [the patient] ... Mom stated that during one of the hospitalizations, she was told that PT needed residential placement ... Mom stated that she is willing to take the PT home but she will probably end up back at crisis the next day ..."

c. A Discharge progress note that stated, " ... CIS (crisis intervention screener) reviewed the crisis safety discharge plan with PT and [the patient]'s mother. Dispo (disposition) was given to Staff #CH29. PT and mom were OK with plan ..."

(i) The "CRISIS INTERVENTION SAFETY PLAN/DIS[title cut off by patient label]," included in both the medical record and the crisis screening notes, identified a provider and a phone number, and an attached list for resources. The remaining sections titled "AGREEMENT TO SAFETY", that outlines the agreed upon safety plan with the patient, and "MEDICATIONS" were not completed. This document was signed by the crisis screener but was not signed by the patient or the patient's legal authorized representative and was not witnessed.

4. An interview with Staff #CH16 confirmed that the crisis screening document available to the physician, the "ED CRISIS SCREENING SUMMARY," did not give an accurate description of the crisis assessment of the patient, and Staff #CH16 reconfirmed that the ED physician does not have access to the crisis screening notes at the time of care of the patient.

5. The medical record lacked evidence of the content of the discussion between the crisis screener and the ED physician before the patient was discharged, including pertinent assessment findings.

6. The recommended interventions and disposition in the medical record, included on the "CRISIS INTERVENTION SAFETY PLAN/DIS[title cut off by patient label]" were not completed, and were not signed or witnessed by the patient or the patient's legal authorized representative.

7. The above findings were confirmed with Staff #CH16.