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Based on hospital policy review, medical record review, behavioral health unit census review, physician on-call schedules and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 17 sampled patients presenting to the hospital's Dedicated Emergency Department (DED) with an emergency medical condition (EMC) who was discharged (Patient #15).

The findings include:

The hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 17 sampled patients presenting to the hospital's Dedicated Emergency Department (DED) with an emergency medical condition (EMC) who was discharged (Patient #15).

~cross refer to 489.24(d)(1-3), Stabilizing Treatment - Tag A2407.

Based on hospital policy review, medical record review, behavioral health unit census review, physician on-call schedules and staff and physician interviews, the hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 17 sampled patients presenting to the hospital's Dedicated Emergency Department (DED) with an emergency medical condition (EMC) who was discharged (Patient #15).

The findings include:

Review of the hospital's policy, "EMTALA Compliance", reviewed 09/2014, revealed, "...In order to comply with the Emergency Medical Treatment and Labor Act (EMTALA), it is the policy of (Hospital A) to require that any patient who presents to the Emergency Department must receive an appropriate medical screening examination to determine if that patient has an emergency medical condition. If so, the patient's condition must be stabilized prior to discharge...EMTALA ends when the patient is stabilized...".

Closed DED (dedicated emergency department ) record review on 04/15/2015 of Patient #15 revealed a 50 year-old female who presented to Hospital A's DED on 01/25/2015 at 1458 via law enforcement under an IVC (involuntary commitment) petition for a psychiatric evaluation. Record review revealed Patient #15 was triaged at 1416 by a registered nurse (RN). Review of the triage documentation revealed Patient #15 had been "acting paranoid for 2 hours...suffers from depression...current psychiatric treatment in New Jersey...wants her name tag attached to her foot...". Further record review revealed a police officer remained at Patient #15's bedside. Record review revealed Patient #15 was experiencing auditory hallucinations, was talking excessively about unusual topics, was trembling and pacing with clenched fists. Record review revealed a current medication list for Patient #15 was obtained at triage and included: Albuterol inhaler, Calcium Carbonate, Vitamin D, Divalproex (mood stabilizer), Hydroxyzine (anti-anxiety), Levothyroxine (thyroid), Losartan (high blood pressure), Metformin (diabetes), Ziprasidone (anti-psychotic), Capsaicin cream (pain), Gabapentin (anti-seizure), Meloxicam (treats arthritis), Ranitidine (antacid), Trazodone (depression). Record review revealed a medical screening exam (MSE) was started by MD #1 at 1647. Review of the physician's physical examination for Patient #15 revealed the patient was handcuffed at wrists and ankles, vital signs normal, agitated and hallucinating. Further review revealed MD #1 ordered and the patient was administered Geodon (anti-psychotic medication) 20 mg (milligrams) orally at 1715 and Haldol (anti-psychotic) 5 mg IM (intramuscularly) at 1842. Review revealed MD #1's clinical impression was acute psychosis, medical clearance examination, history of bipolar disorder, history of anxiety/depression and history of "multiple medical conditions". Review revealed MD #1 noted a recent discharge from the VA (Veterans Administration) hospital for psychiatry issues. Further review revealed a note by MD #1 at 1835, "Per behavioral nurse, no staff to admit patient here. (Psychiatrist) recommends starting process to transfer patient to (State Psychiatric Facility)".
Record review revealed a behavioral assessment was completed by an RN #2 on 01/25/2015 at 1745. Documentation by the behavioral health nurse (RN #2) revealed, " ...Pt has been IVC ' d by mobile crisis center and police officer is in room. Pt highly agitated and aggressive, pt is in handcuffs and still trying to swing and hit hospital staff and policewoman. Pt is screaming, yelling, rambling thoughts, paranoid and delusional. Poor historian. Pt ' s sister (Name) in New Jersey (phone number) happened to call, she is her sister ' s healthcare power of attorney, she stated her sister has been battling bipolar disorder with psychosis for over 25 years. She reported that her sister was a patient here on our behavioral health unit for 14 days in November of 2014 and the physician told her there was nothing else we could do for the patient and she was transferred to Durham VA where she has been a patient since being discharged this past Friday 01/23/2014 (sic 2015) ...the patient does not have a caregiver, she picks random people to live with her, and the sister stated that she was dropped off at her house by a taxi. No one heard from her since being discharged and finally her sister got a hold of her yesterday. She was paranoid, delusional, had racing thoughts and speech very manic sounding. Her sister called mobile crisis and they went to assess her, stated she was highly psychotic and a danger to herself and others and they IVC ' d her. In the ER room, the patient is non-compliant with instructions, refusing to give a blood sample, and then decided due to the lab technician wearing a blue uniform he looked like a huge ocean wave, and she likes the ocean so therefore he was allowed to draw her blood. Pt kept calling people names, and reciting nursery rhymes. (Name of Psychiatric Hospital) due to her highly psychotic state. Pt ' s ER physician, (MD #1) aware of (On-Call Psychiatrist) decision " .

Record review revealed a psychiatric consult was ordered and completed by MD #2 on 01/26/2015 at 1210. Review of MD#2's dictated consult note revealed, "...the patient was admitted from 11/21/2014 - 12/01/2014 (at Hospital A) for an involuntary status for agitation, delusion, threatening staff, placing self in dangerous situation...She was a former VA (veteran's) patient and had apparently been treated at the (Name of VA Hospital) and was accepted there and transferred there on 12/01. She apparently was there until discharge on 01/23, 3 days ago, and while there was reportedly on the waiting list for ( State Psychiatric Facility). She came home and has been acting inappropriately, has been irritable, aggressive, agitated. She claims people were stealing from her. This is not unusual compared to her prior presentation...significant for chronic mental health issues, noncompliance with treatment, and multiple hospitalizations with rapid readmission...IMPRESSION: This is an adult female with schizoaffective disorder...RECOMMENDATIONS: Second evaluation was performed. We continued her on involuntary commitment...she has been placed on the waiting list at (State Psychiatric Facility)". Further record review revealed the patient required Geodon 20 mg IM on 01/26/2015 at 2330, Haldol 5 mg IM on 01/27/2015 at 0613, 01/28/2015 at 2045, 01/29/2015 at 0145 and 1842, Geodon 20 mg IM on 01/30/2017 at 0117 and 0854. Further review revealed Patient #15 had episodes of yelling and swearing at staff, leaving her room and wandering into other patient rooms, grabbing items off stretchers and desks from drawers and had to be constantly redirected by staff. Further review revealed Patient #15 was placed on the high priority list at the State Psychiatric Facility. Record review revealed a nurses's note on 01/30/2015 at 1245, "Spoke with (MD #2). He saw pt this AM in ED. Pt denies any SI (suicidal ideation), HI (homicidal ideation), AVH (auditory/visual hallucinations). She is not felt to be a harm to herself or any other. (MD #2) states he will do a change of commitment and will D/C (discharge) patient to home...". Record review revealed a "Notice of Commitment Change" with the box checked, "The respondent is no longer in need of inpatient hospitalization and is unconditionally discharged on 01/30/15", signed by MD #2. Record review revealed Patient #15 was discharged to home via taxi on 01/30/2015 at 1558.

Closed medical record review from Hospital B revealed Patient #15 presented to the DED on 02/03/2015 at 1727 via law enforcement after patient was found walking down the side of a road (4 days after discharge from Hospital A). Record review revealed the patient was medically screened at 1745 and was involuntary committed to Hospital B's inpatient behavioral unit. Review of the physician's dictated admission history and physical revealed, "...Chief Complaint: 'Thank God you're blue'...the patient is not really able to answer other questions because of the severity of her psychotic thinking. Currently she seems to be very disorganized and psychotic...Diagnosis: Axis I: Bipolar disorder, manic...". Record review revealed Patient #15 was discharged from Hospital B on 03/12/2015 to home with her sister.

Review of Hospital A's daily census report for the behavioral health unit revealed a census of 14 on 01/25/2015; 15 on 01/26/2015; 19 on 01/27/2015; 20 on 01/28/2015; 25 on 01/29/2015; and 24 on 01/30/2015. Further review revealed the census on 01/26/2015 included two new admissions to the acute behavioral unit from 01/25/2015 until 01/26/2015, three new admissions to the acute behavioral unit on 01/28/2015, one new admission on 01/29/2015 and 01/30/2015 to the acute behavioral unit.

Review of Hospital A's DED physician specialty on-call schedule revealed a psychiatrist on-call daily from 01/25/2015 through 01/30/2015.

Interview on 04/15/2015 at 0900 with the Clinical Director of Hospital A's behavioral health unit revealed the capacity for patients on the behavioral health unit is 30, with an average daily census of 18 to 20 patients. Interview further revealed the unit has four acute beds for the "more psychotic patients ". Interview further revealed the unit does accept and admit IVC patients. Interview revealed, "(Patient #15) had been in our unit in early January. She was transferred to the VA. She was there 30 days". Interview revealed, "she did not meet our criteria for admission on January 25th. We didn't have any inpatient acute beds. She needed a higher level of care therefore she needed long-term interventions. We put her on the Central (State Psychiatric Hospital) waiting list. We had an empty bed on January 29th. She got better on meds (medications) so she was discharged. She was safe for discharge".

Interview on 04/15/2015 at 0830 with MD #1 revealed he performed the medical screening examination for Patient #15 on 01/25/2015. Interview revealed, "she was handcuffed by the police. She was loud and abusive toward staff, not physically. A psych consult was ordered and done by (MD #2). I don't know what the census was on our behavioral unit. We have a lot of elderly patients so we don't want aggressive patients on our unit. She had been admitted here in the not so distant past, maybe November 2014. Her IVC was rescinded by (MD #2). I don't know if she was safe for discharge. For the majority of these cases, it is the psychiatrist's decision".

Interview on 04/15/2015 at 0915 with Nurse Practitioner #1 revealed, "I first saw her (Patient #15) on January 27th. She was not stable, was wandering around, having visual and auditory hallucinations. She was stabilized with Geodon and Haldol. I saw her again on January 29th. She was calm and cooperative. She was still IVC'd. I offered her an inpatient bed and she refused. I went back to see her on January 30th. She had been discharged".

Interview on 04/15/2015 at 1055 with RN #1 revealed she discharged Patient #15 on 01/30/2015. Interview revealed, "she was wandering the halls at 1022 and had to be redirected. She asked to call the 'Blue Team'. I never knew what that was. She requested her IV pole and she didn't even have an IV. She was banging her hand on the bed wanting her specific brown underwear. At the time of discharge, she was calm, had eaten and was safe for discharge".

Interview on 04/15/2015 at 1140 with RN #3 revealed the nurse is a case manager in the DED. Interview revealed she remembered Patient #15. Interview revealed, "she was yelling and screaming the whole time. She was psychotic and was not capable of making decisions".

Interview on 04/15/2015 at 1130 with MD #3 revealed the MD was the DED physician at the time of Patient #15's discharge on 01/30/2015. Interview revealed, "(MD #2) released her from her IVC and recommended she follow-up with the VA. She needed intermittent medication and there was no need for continuous hospitalization. I agreed with (MD#2)".

MD #2 was on medical leave and not available for interview.

In summary, Patient #15 presented to Hospital A's DED on 01/25/2015 under IVC with psychosis. Hospital A had a behavioral health unit with capacity and capability to accept Patient #15 as an inpatient. Hospital A discharged Patient #15 via taxi to home on 01/30/2015 (6 days in Hospital A's DED) and the patient was found by law enforcement walking down the side of a road 4 days later and was admitted to Hospital B's behavioral health unit on 02/03/2015 with discharge on 03/12/2015.

NC00104561