HospitalInspections.org

Based on document review and interview, the facility staff failed to :
Admit and prevent the delay in treatment for psychiatric illnesses for one (1) of six (6) patients (Patients #2) while failing to release EMS and law enforcement personnel and equipment that could impact other community members by not being able to provide emergency services.

The findings include:

The Medical Record from Hospital #1 (the sending hospital) provided the following information:
Patient #2 initially presented to the Hospital with a history of Dementia, Alzheimer's type. (This information was faxed to the receiving facility on March 24, 2019 at 4:19 P.M., almost twenty-four (24) hours prior to arrival at this facility.) The medical record read "...Patient was seen in January [Name of Hospital #1] for similar presentation where [he/she] had been confused at a local store near [his/her] home with some visual hallucinations. At that time, the patient was sent on a temporary detention order to [Name of another hospital not involved in this complaint]. At the time of this initial assessment by this clinician, the patient presented as confused was mumbling at times in [his/her] speech and made little sense. The patient denied any SI/HI (suicidal or homicidal ideations) and did not appear to be hallucinating at the time. While clinician was discussing information with patient's [spouse], the Dr. was notified the patient has begun to appear to be hallucinating having both auditory and visual hallucinations, reporting [he/she] is hearing gunshots and sees things moving on the walls. The patient is currently presenting with some paranoia which the [spouse] reported [he/she] was experiencing at the time of [his/her] last admission.

Review of Systems: Except as documented in HPI (History of Present Illness), all other systems are negative."

Medical Record from Hospital #1 (sending hospital) revealed:
Patient #2 was initially seen at Hospital #1 on 3/23/19 at 3:05 P.M. Patient #2 was seen by the CSB (Community Service Board) on 3/23/19 at 10:30 P.M. for an evaluation. Patient #2 was determined to not be able to make appropriate care decisions and a TDO (Temporary Detention Order) was issued. A bed search (a search for a facility with the capabilities to care for the Patient) was initiated. Hospital #1 faxed information related to Patient #2's history and present condition to this facility on 3/24/19 at 4:19 P.M. The on-call psychiatrist (Staff Member #14) was contacted by Staff Member #13 on 3/25/19 at 1:59 A.M. who provided the psychiatrist with information from Hospital #1. Staff Member #14 approved the admission to the facility's Gero (geriatric) Unit via the TDO. Report from a nurse at Hospital #1 was called to a nurse at this facility at approximately midnight. Hospital #1 reported Patient #2 would be departing their facility at approximately 8:10 A.M. on 3/25/19.

Patient #2 arrived at this facility 3/25/19 between 8:10 A.M. and 1:40 P.M.

During an interview on 9/16/19 at approximately 11 am, Staff Member #4 of the receiving facility stated, "Once the patient (Patient #2) arrived the nurses from the unit are called to the TDO holding area and the assessment begins. The nurse who started the assessment called the PA (Physician's Assistant - Staff Member #5) and asked for them to assess the patient (Patient #2)." Staff Member #5's assessment was dated 3/28/19 at 1:00 P.M. as a Late Entry for 3/26/18 encounter (note: the medical record date documented as "3/26/18" was incorrect for day and year). The assessment read, "Patient was evaluated on arrival to the Pavilion. [He/She] was noted to have waxing and waning attention and appeared distractible. [He/She] unable to follow commands or provide meaningful answers to questions. [He/She] did deny pain. There was no sign of acute psychiatric emergency. Mental state appears consistent with delirium or acute confusional state. As patient required further medical intervention beyond what the Pavilion is equipped to provide, advised nursing supervisor that accepting patient to our facility would against [his/her] interest. Case was discussed the [Name of Hospital #2] ED (Emergency Department) provider [Name of ED Provider] the same afternoon and above findings were reiterated."

Staff Member #5 was interviewed on 9/16/19 at approximately 1:30 P.M. and stated, "I believe the nursing supervisor asked me to evaluate the patient. There appeared to be more medical issues than psych issues. [He/She] couldn't state [his/her] name. I was concerned about underlying medical condition. I believe there was medical information from the sending hospital for me to review. I spoke with [Name of Staff Member #12/Supervising Physician] and [he/she] agreed with my assessment. Later that day I received a call from [Name of Physician at Hospital #2]. They did not ask if we could take the patient (Patient #2) back that I recall. [Name of Physician at Hospital #2] didn't ask many questions, they just listened. I interact with [Name of Staff Member #12] more than the psychiatrist. The admissions department will ask us to look at information prior to accepting a patient. If there is a time we should be consulted, it's over night. I did not contact the psychiatrist prior to advising the nursing staff to send the patient (Patient #2) to the ED."

Patient #2 had been transported from Hospital #1 to this facility which was approximately three (3) hours apart.

Staff Member #3 (Chief Nursing Officer) was interviewed on 9/16/19 at approximately 12:20 and stated, "The patient (Patient #2) arrived around 10:00 A.M. The P.A. assessed the patient (Patient #2) and denied the admission. We assumed the ambulance crew called their hospital but instead they took the patient (Patient #2) to [Name of Hospital #2]."

A review of Hospital #2's medical records for Patient #2 was performed on 9/16/19 and the following information was noted:
Patient #2 arrived at Hospital #2 on 3/25/19 at approximately 1:40 P.M. via EMS with Altered Mental Status, Auditory and Visual hallucinations. Final diagnoses was Unspecified dementia without behavioral disturbance.
The ED physician at Hospital #2 documented, "...This morning patient was d/c (discharged) to the [Name of this facility]. Upon arrival to the [Name of this facility] pt (Patient) was not accepted and transporter was told to bring back to [Name of Hospital #1]. 30 (Thirty) minutes after leaving the [Name of this facility], pt (Patient #2) apparently got "inappropriate" and transport was instructed to bring pt (Patient #2) to the nearest ED..."
The Physical Exam noted all systems had no medical issues except "Psychiatric: [His/Her] affect angry. [His/Her] speech is rapid and/or pressured. [He/She] is agitated."

Hospital #2's ED notes revealed the following time line starting on 3/25/19:
1:40 P.M. upon arrival to ED Patient was yelling, kicking and uncooperative. Physician at bedside, Patient in forensic wrist restraints. Patient given 5 mg (milligrams) of Haloperidol, 25 mg of Benadryl and 2 mg of Ativan via IV (intravenous).
2:15 P.M. Patient medically cleared but sedated.
2:43 P.M. ED paged the sending facility (this facility) physician.
2:55 P.M. [originating] County Sheriff at bedside, CSB contacted.
3:56 P.M. ED staff made third contact with this facility. Informed PA and medical director
are off the premises and are aware the ED physician needs to speak to them.
4:46 P.M. Contacted again as this facility physician still has not contacted 9Hospital #2) ED Physician.
4:47 P.M. ED physician speaking to P.A. from this facility.
4:53 P.M. Patient remains 1:1 with security and officer from [originating] County.
5:40 P.M. CSB from sending (originating) county requesting medical records be sent to Hospital #3.
6:50 P.M. Remains 1:1 with security, forensic wrist restraints remain in place.
7:55 P.M. Police from [county of this facility] now in place with security 1:1. Patient has no
logical words.
7:45 P.M. Patient with restless and agitated behavior; Patient is very agitated when moved
or touched; Yells out tries to hit or pinch; remains in forensic restraints and police
and security at bedside.
10:20 P.M. Spoke with [transport Company #1] unable to transport due to distance.
10:21 P.M. Spoke with [transport Company #2] told to call back at 7:30 A.M. on 3/26/19.
10:29 P.M. Spoke with [transport Company #3] told could not make the trip until 9:00
A.M. 3/26/19.
10:32 P.M. Spoke with [transport Company #4] told unable to accommodated due to distance.
10:36 P.M. Spoke with [transport employee] at unknown transport told unable to accommodated due to distance.
10:54 P.M. Spoke with [transport Company #5] told unable to transport as crew in Savannah GA.
10:56 P.M. Spoke with [transport Company #6] unable to transport tonight.
11:00 P.M. [Company #7] Ambulance Service unable to transport due to only one crew on.
3/26/19
12:24 A.M. Patient remains in forensic restraints with police department (PD) at bedside.
5:27 A.M. mumbles incoherent words; 1:1 sitter and PD at bedside.
7:15 A.M. PD at bedside; [transport Company #2] to call back with ETA (Estimated Time of Arrival).
7:47 A.M. Handcuffs removed; Patient calm.
8:08 A.M. [transport Company #2] awaiting additional crew member.
9:12 A.M. [transport Company #1] can not transport due to insurance not covering over 100 miles.
9:24 A.M. [transport Company #2] updated - [transport Company #8] will be here at 3:00 P.M. to transport.
9:45 A.M. [transport Company #3] will have a crew here at 1:00 P.M.
12:24 P.M. attempting to obtain vital signs Patient pushed tech away but was not harmful.
2:33 P.M. [transport Company #3] transport present to transport Patient.
2:36 P.M. Patient discharged to be admitted to Hospital #3 approximately three (3) and
one half (1/2) hours away from Patient #2's current location.

Patient #2 received no psychiatric intervention from 3/23/19 to 3/26/19 (three (3) days) and rode a total of six (6) and one half (1/2) hours in ambulances. Patient # 2 was in the custody of Emergency personnel (ambulance and law enforcement) from approximately 3/23/19 at 10:30 P.M. until Patient #2 arrived at Hospital #3 on 3/26/19 at approximately 6:00 P.M.



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