HospitalInspections.org

Based on document review and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that an individual who came to the emergency department (ED) for an emergency medical and psychiatric examination was provided with a complete and comprehensive medical screening examination. (A-2406)

Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt. #1) reviewed for patients with psychiatric complaints, the Hospital failed to ensure an individual who came to the emergency department (ED) was provided with a complete medical screening examination.

Findings include:

1. On 12/21/2021, the Hospital's policy titled, "Emergency Department General Policy and Provision of Emergency Services (EMTALA - Emergency Medical Screening and Treatment of Patients)," reviewed by the Hospital on 10/12/2020, was reviewed. The policy required, "Scope of Service: The Emergency Department [ED]... is designed and equipped to facilitate the immediate treatment of any medical or surgical emergency, to initiate lifesaving procedures in all types of emergency situations, and to provide emergency care for other conditions... Roster of Medical Specialists... Psychiatry..."

2. The clinical record of Pt. #1 was reviewed on 12/20/2021. Pt. #1 presented to the Hospital's emergency department (ED) on 12/5/2020 at 3:27 PM with chief complaint of "acting erratic".

- The ED history of present illness (HPI), [per ED Physician, MD #2] dated 12/5/2020 at 3:28 PM, included, "presents to the ED via EMS [emergency medical service] with PD [police department] escort for psychiatric evaluation d/t [due to] erratic behavior just PTA [prior to admission]. Additional history provided by the clerk at the gas station. Reported he saw the patient [Pt. #1] head towards the restroom with an unidentified white powder. PD was contacted by gas station staff, after the patient was attempting to shop lift from the store. Upon PD arrival and subsequent arrest, [Pt. #1] began to behave strangely and appeared to be under the influence. While PD was transporting, the patient started breathing loudly, prompting them to contact EMS. [Pt. #1] received Narcan [treats narcotic overdose] x1 [one time]. On arrival the patient is refusing to answer questions. The HPI is limited due to uncooperative patient."

- A physical examination [by MD #2] included: "General: Alert, no acute distress." Skin, Head, Neck, eye, ears, nose mouth and throat, cardiovascular, respiratory, gastrointestinal and musculoskeletal all reported as normal. "Neurological: No focal neurological deficit observed, uncooperative patient, nonverbal, moving extremities spontaneously. Psychiatric: cooperative, appropriate mood & affect. ... The medical decision making included: Diagnosis' include the following: polysubstance abuse, malingering, overdose and electrolyte abnormality."

- A physician's order [MD #2], dated 12/5/2020 at 3:34 PM, included, "Consult to Social Services, Psych [psychiatric] evaluation."

- A social service (E #5) note, dated 12/5/2020 at 3:54 PM, included, "Patient came here for acting erratic in-route to the police station... Patient currently is not talking and refusing to answer questions. Patient is in police custody. No petition has been completed at this time." No subsequent social service notes or psychiatric assessment were found.

- The discharge note (by MD#1), dated 12/6/2020 at 1:07 AM, included, "after several hours of emergency room observation, patient awake, alert, normal gait, denies SI/HI [suicidal ideation/homicidal ideation]. Returned to baseline ... Condition: stable, Disposition: discharge to home."

3. The discharging ED physician (MD#1) was interviewed on 12/20/2021 at 11:00 AM via telephone. MD#1 stated that Pt. #1 had erratic behavior upon arrival to the ED. Pt. #1 was immediately placed in a room and assessed. MD#1 stated, "We try to figure out if the behavior is psychiatric in nature or drug related. A social worker was consulted to evaluate if psychiatric services would be needed. In this case, it was deemed unnecessary for further psychiatric evaluation. [Pt. #1] denied any psychiatric history. [Pt. #1] had a positive urine for THC [cannabis]." Pt. #1 was reevaluated by MD#1 and remained in the ED to "cool off" until it was safe to discharge. MD#1 stated, "I would not have ok'd the discharge if I felt the patient wasn't stable." MD #1 stated that Pt. #1 was discharged into the waiting room until arrangements for a ride could be made. Pt. #1 began bothering other patients, and the staff called the police to have Pt. #1 removed from the hospital. Pt. #1 was not brought back to the ED treatment area for reassessment related to abnormal behavior exhibited in the waiting area post discharge.

4. The Security Log for 12/5/2020 was reviewed on 12/21/2021. Pt. #1 was included on the list two times. The first was on 12/5/2020 at 5:35 PM for a contraband check in the ED. The second was on 12/5/2020 at 10:15 PM. The log included: Security officer was escorting Pt. #1 from the ED to the ED waiting room area to call for a ride. Pt. #1 tried to call someone using the ED telephone, but was unable to remember the phone number. Pt. #1 did not have a cell phone. Pt. #1 was offered to wait in the waiting room until a ride could be arranged. While waiting, Pt. #1's behavior became a safety issue. Pt. #1 began to display manic erratic behavior by stomping feet and hollering for no apparent reason. Pt. #1 was told by security if the behavior continued, Pt. #1 would be escorted off the hospital campus. Security officer requested that the ED charge nurse (E #7) contact the police department that brought Pt. #1 to the hospital to see if they had any family or friend contact information available. Due to the safety concern for other patients in the waiting area, the local police department was contacted at approximately 10:43 PM. The local police department arrived at 10:51 PM. The police were informed that Pt. #1's behavior could not be tolerated, and the police escorted Pt. #1 out of the hospital. Per the report, the local police took Pt. #1 to the border of Orland Park in the vicinity of Wolf Road.

5. The ED charge nurse (E #7), mentioned in the above security report, was interviewed on 12/21/2021 at 10:00 AM. E #7 stated that she had been informed of a disturbance in the waiting room. Security had already responded. Pt. #1 had been discharged and was waiting for a ride. E #7 stated, "I was told that a discharged patient was being loud and bothering other people in the waiting room. Since this is considered a disturbance, I told security to call the police for assistance." E #7 stated that if people are not able to be calmed down while in the waiting room, it is normal to call the local police to handle the situation. "Since the patient was deemed stable for discharge, security handled the situation."

6. The Public Safety Officer (E#9), who responded to Pt. #1's event in the ED waiting room, was interviewed on 12/21/2021 at 12:20 PM. E#9 stated that he was sitting in the security office and heard a loud outburst in the ED waiting room. E#9 went to the area and asked if he could be of assistance. Pt. #1 wanted to wash up in the bathroom. E#9 told Pt. #1 that Pt. #1 could wait for a ride but could not use the bathroom to wash. E#9 stated, "[Pt. #1] wanted to go into the children's area to pray. We allowed that. [Pt. #1] continued with some loud outbursts that were bothering other people in the waiting room. [Pt. #1] would sit down and jump up and talk loudly. I tried to tell [Pt. #1] that he had to stop. [Pt. #1] stopped intermittently but continued to have periodic outbursts. I went to the ED and was told that [Pt. #1] had been discharged and there was no need to receive further treatment." E#9 stated that since Pt. #1 continued with periodic outbursts, he called the local police department to assist with escorting Pt. #1 out of the hospital.

7. The ED Medical Director (MD#3) was interviewed on 12/21/2021 at 11:23 AM. MD#3 stated, "In the case of [Pt. #1], the patient was monitored for a significant amount of time and determined to be stable for discharge. The disturbance was caused when [Pt. #1] had already been discharged and was no longer considered a medical patient of the hospital. Security handled the situation as required."

8. The Social Service (E#5) representative, who evaluated Pt. #1, was no longer employed at the Hospital and was not available for interview.

9. MD #2 was not available for interview during this survey due to MD #2 was not on call and did not respond to calls made attempting to conduct an interview.

10. Pt. #1 was not provided a comprehensive psychiatric assessment and was not reassessed by ED medical staff when informed of Pt #1 displaying "manic erratic behavior" in the waiting area after discharge.