HospitalInspections.org

Based on review of medical records, review of policy and procedure, ambulance report review, review of bed census reports and staff interviews it was determined the facility failed to ensure an individual which presented to the facility and was determined to have an emergency medical condition was not provided stabilizing treatment as required within the capabilities of the staff and facilities available at the hospital, for one (#9) of twenty-two patients sampled prior
to discharge.

Based on review of medical records, review of policy and procedure, ambulance report review, review of bed census reports and staff interviews it was determined the facility failed to ensure an individual which presented to the facility and was determined to have an emergency medical condition was not provided stabilizing treatment as required within the capabilities of the staff and facilities available at the hospital, for one (#9) of twenty-two patients sampled prior
to discharge.

Findings included:

Review of the facility policy, "EMTALA - Medical Screening and Stabilization", last revised 2/26/2016, states in part, " ...7. Stabilizing Treatment Within Hospital Capability ...c. Stabilizing Treatment and individuals whose EMC's are resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work -up and/or treatment could reasonably be performed as an outpatient or later as an inpatient, provide the individual is given a plan for appropriate follow-up care with discharge instructions. The EMC that caused the individual to present to the DED must be relieved or eliminated, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release form the hospital."


Review of the County Fire Rescue Medical Encounter Report Form dated 4/30/2018 was reviewed. The report indicated that EMS arrived to the scene where patient #9 was located at 23:16. The patient medications were listed as Zoloft (medication used to treat depression), Amoxicillin (Antibiotic-medication used to treat infections), Haldol (Anti-psychotic medication used to treat schizophrenia), and Geodan (Anti-psychotic drug used to treat schizophrenia and Bi-Polar disorder). Review of the narrative revealed that EMS was dispatched because Patient #9 was complaining of a headache. The EMS personnel documented upon arrival patient #9 did not appear to be in any distress. Further review revealed upon contact the patient reported that he has had a headache for approximately 2 hours. Patient reported that he has a psychiatric history and has been non complaint with his medication for approximately 2 weeks, causing him to have random suicidal thoughts. The patient was able to walk to the rescue under his own power, sat on the stretcher, secured with straps, and loaded in the rescue without incident. Further review revealed that patient #9 was transported to Brandon Regional Hospital without incident, and full report was given to the ED staff nurse.

Review of the medical record for patient #9 revealed the patient arrived to the facility's ED (Emergency Department) on 4/30/2018 at 11:34 pm via EMS (Emergency Medical Services). Review of the record revealed a physician performed a MSE at 11:38 pm. The physician documented the patient had a past medical history of schizophrenia, depression and anxiety. The physician documented the patient presented with suicidal ideation's with no stated plan, the patient's affect was depressed, flat and he was suicidal.

Review of the physician orders revealed on 4/30/2018 at 11:37 pm the physician ordered a consultation with the Behavioral Health Unit Intake Coordinator. Review of the record revealed the physician completed the Certificate of Professional Initiating Involuntary Examination on 4/30/2018 at 11:48 pm. Review of the Certificate of Professional Initiating Involuntary Examination dated 4/30/2018 at 2348, revealed in part, " ...Criteria: there is reason to believe person has mental illness ...Diagnosis of Mental illness is ...Depression ...AND BECAUSE OF MENTAL ILLNESS ...Person is unable to determine for himself/herself whether examination is necessary ...and either there is substantial likelihood that without care or treatment the person will cause serious bodily harm to self."

Documentation revealed the physician medically cleared the patient on 5/01/2018 at 1:14 am. Review of the facility's in-patient Behavioral Health Unit midnight census for 5/01/2018 was 18 with a capacity of 25. The unit had the capability and capacity to admit the patient.

Review of the medical record revealed nursing documentation, dated 5/01/2018 at 1:46 am, which stated telephone communication, with an independent organization used to assist in bed placement for patients with behavioral health diagnosis, requesting a bed for the patient. Documentation stated the BA (Baker Act) paperwork was also faxed at that time. Review of the record revealed no evidence the ED staff requested bed placement on their behavioral health unit. Review of the nursing documentation on 5/01/2018 at 4:31 am revealed the organization used to assist with bed placement was called again regarding placement of the patient. Documentation stated the patient will be on hold for 12 hours in the ED because he has no insurance.

Review of the physician documentation at 6:02 am on 5/1/2018 stated the patient was pending bed assignment by the organization and the patient's status was unchanged. At 6:23 am the physician documented the patient's continued care was transferred to the oncoming ED physician and the patient's complaints and labs were discussed.

Review of the medical record revealed the ED physician documented at 9:07 am on 5/1/2018 that the patient was seen by the licensed mental health worker and the ED physician was asked by the licensed mental health worker to rescind the Baker Act per her telephone conversation with the psychiatrist. Documentation by the ED physician stated he told the licensed mental health worker the patient should be seen by the psychiatrist for further evaluation.

Review of the Behavioral Health intake specialist note, dated 5/01/2018 at 12:22 pm, stated she met with the patient for a brief assessment. She stated the patient felt "alright" and denied all suicidal ideation, homicidal ideation, auditory or visual hallucinations. He stated "I guess I can be let go". Documentation stated the patient will be provided community resources and a bus pass. The patient was discussed with the on-call psychiatrist.

Review of the record revealed the psychiatrist evaluated the patient on 5/01/2018, no time noted.
The psychiatric consult note, stated in part, "Reason for Consult: Evaluate patient with Baker act ...history of Present illness: Patient is well known.. Presents with suicidal ideation, once had a good night's sleep ... deny any suicidal ideation and requested to be discharged. ...Denies any intent to harm himself or others. Has been appropriate with ER staff. ...Mental Status Exam: awake alert, and oriented x4 ...thought process: coherent and goal directed ...thought content: within normal limits. Short term: intact. Long term: intact...Insight/Judgement: insight intact, judgement intact. Assessment and Plan ...Will lift Baker act, Patient psychiatrically cleared for discharge. No discharge prescriptions were written.

Review of the ED physician documentation on 5/01/2018 at 12:51 pm validated that Patient #9 was evaluated by the psychiatrist and the Baker Act was rescinded. The patient was discharged from the facility at 12:50 pm.

An interview was conducted on 6/22/2018 at 3:45 pm with the Risk Manager/Director of Patient Safety, BHU (Behavioral Health Unit) Program Director and Behavioral Health Unit Director. The BHU Director and Program Director confirmed the BHU had capacity and capability.
The facility staff failed to ensure that their own policy and procedure was followed as evidenced by the facility staff failed to ensure that Patient #9's discharge instructions included discussion regarding the reason for his noncompliance with his psychiatric medications prior to discharge. As patient stated to EMS that he was noncompliant with his meds which caused him to have random suicidal ideations; and it was determined by the ED physician that on 4/30/2018 the patient had an emergency psychiatric medical condition. There were no prescriptions given to the patient upon discharge. There was no discussion whether or not the patient had remaining psychiatric medication at home or if he had access to his psychiatric medication upon discharge.