HospitalInspections.org

Based on staff interview, document, and medical record review, the Critical Access Hospital (CAH) failed to ensure medical staff followed bylaws, rules, and regulations approved by the governing body to provide a medical screening exam and stabilizing treatment for 1 of 23 medical records reviewed (Patient #1). This failure could result in the potential harm for all patients treated at the CAH.

Findings include:

Governing body bylaws reviewed on 3/14/2016 at 7:15 PM revealed the Governing body had the following specific duties: C) Maintain a physical plant, equipment, personnel and other resources to adequately meet the needs of the Hospital and its patient and ensure adequate resources are available to implement the Hospital's provision of health care and other services; d) Ultimate responsibility for the provision of the health care provided in the hospital.
Medical Staff Rules and Regulations reviewed on 3/14/2016 at 7:30 PM directed "... Community mental health providers may assist by facilitating the transfer of psychiatric or substance abuse patients. The medical screening and stabilization requirements remain unchanged for this population of patient ..."

- Patient #1's medical record reviewed on 3/9/2016 at 11:15 AM revealed the patient presented to the Emergency Department (ED) on 1/23/16 at 2:35 PM for "Suicidal Ideation" (thoughts of suicide). The medical review revealed Patient #1 became verbally abusive and increasingly aggressive. The medical record lacked evidence Physician Staff B and the contracted mental health screener continued the medical screening process to provided necessary treatment to stabilize Patient #1's emergency medical condition. Physician Staff B discharged Patient #1 to jail prior to their condition being stabilized. The medical record revealed Registered Nurse Staff I failed to communicate the need for further documentation ensuring the patient no longer had an EMC before allowing a discharge..


Physician Staff B interviewed on 3/10/2016 between 9:00 AM and 9:30 AM acknowledged when they documented the patient was medically stable in the record they were not concluding the patient was psychiatrically stable. Staff B indicated an individual presenting to the ED with acute psychiatric symptoms was having an emergency medical condition (EMC). Staff B acknowledged Patient #1 was in fact not stable for discharge or transfer at the time they were arrested and allowed to leave with the police officers.

Physician Staff K (ED Medical Director at time of incident) interviewed on 3/10/2016 between 10:00 AM and 10:20 AM acknowledged a person with psychiatric symptoms is considered to have and EMC. Physician Staff K indicated they had not made plan of care decisions prior to Physician Staff B assuming care, but felt Patient #1 would not be safe for discharge prior to their end of shift. Physician Staff K acknowledged a patient can only be discharged if both psychiatric and physical EMC's are stabilized.

CEO Staff L, interviewed on 3/16/2016 between 8:05 AM and 8:20 Am indicated that they had no knowledge of the incident prior to this survey. Staff L acknowledged after briefly reviewing the incident they agree "we did the wrong thing" by allowing a patient with an emergency medical condition to be discharged prior to providing stabilizing treatment. Staff L indicated the nursing staff followed their chain of command and mental health policy by notifying the CNO/COO of the potential discharge. However, the discharge was allowed to proceed prior to stabilization and against their EMTALA policy.

Registered Nurse Staff M (ED Director) interviewed on 3/11/2016 between 8:30 AM and 9:30 AM revealed the RN staff has Mental Health patient packets with a checklist to help them with this patient population. A document within the packet titled "Behavior Health Patient Discharge Criteria" directs "...Continued status is necessary until all of the following are met: Risk Status Absence of thought of suicide, homicide, or serious harm to self of another ..." and "... if documentation does not support "stable for discharge" the primary nurse will be directed to communicate the need for further documentation to the ED physician and/or primary care physician.

RN Staff J's notes reviewed on 3/9/2016 at 1:40 PM revealed at 6:09 PM patient #1 had a Xanax on the counter and was seen snorting the crushed Xanax. Staff J noted both Physician staff K and Physician Staff B agreed involuntary admission was necessary. At 6:43 PM patient #1 states, "I'm going to try to hang myself at this hospital too." At 10:34 PM, notes indicate patient #1 is to be a 1:1 observation and notification to security of the need for assistance was made. At 11:07 PM, patient #3 and an officer were having a confrontation, patient requesting officer slam their head into the ground to break their nose. At 11:23 PM, Officers inform nurse they are unable to sit with patient #1 due to staffing issues and indicated they could possible arrest the patient for disorderly conduct. At 11:45 PM, the patient was placed in handcuffs and escorted out of the ED with three officers at their side. RN Staff J acknowledged they did not feel jail is a safe disposition for a patient with an EMC that has not been stabilized and Patient #1 was not psychiatrically stable at the time they left with police. RN Staff J confirmed they contacted the CNO/COO Staff I prior to Patient #1's discharge. Staff J indicated that Staff I agreed with the discharge. Staff J failed to advocate for their patient and ensure stabilizing treatment was provided prior to discharging Patient #1.

Mental Health Worker Staff N interviewed on 3/10/2016 between 10:25 AM and 10:55 AM indicated they performed a mental health-screening exam at about 4:35 PM on 1/23/2016. Staff N reported patient #1 became was very aggressive and started looking for places that would accept them as a patient, but was unable to secure a bed until Monday. Staff N agreed the patient was not safe for discharge and left the facility after Physician Staff B made the decision to place patient #1 in observation until a bed became available. Staff N revealed a police officer called and asked if the patient had been aggressive toward him/her. Staff N stated patient #1 had been and was informed they were arresting the patient and taking them to jail. Staff N reported patient #1 needed to be in a safe environment and felt the observation unit may have given him/her the opportunity to self-harm or harm others. Staff N indicated they did not feel this was a bad decision.

The Critical Access Hospital (CAH) reported a census of 21 patients. Based on observation, staff interview, and policy review the CAH failed to ensure outdated medications and biologicals were not available for patient use in one of one pharmacy. The failure of the CAH to ensure outdated medications and biologicals were not available for patient use has the potential to affect all patients in the CAH.

Findings include:

-The pharmacy observed on 3/14/2016 between 10:15 AM and 11:00 AM revealed four vials of Lidocaine HCI 2% and epinephrine 1:1000,000 (a numbing medication) with an expiration date of 1/1/2016.

Pharmacist Staff A interviewed on 3/14/2016 at 10:30 AM acknowledged they failed to ensure expired medications were properly inventoried and unavailable for patient use. Staff A indicated inventory is conducted monthly by the pharmacy technicians.

- The CAH's policy titled "Outdated Medication Control" reviewed on 3/14/2016 at 7:45 PM directed staff, "...Outdated medications pulled from inventory will be sequestered AWAY from current stock and accumulated for processing by a Reverse Distributer ..."

The Critical Access Hospital (CAH) reported a census of 21 patients. Based on observation, staff interview and policy review the CAH failed to ensure single use sterile supplies remain unopened prior to use for three of three ultrasound rooms and the CAH failed to ensure infection control practices and policies are followed for three observed hand hygiene opportunities. These deficient practices have the potential to cause hospital-associated infections.


Findings include:



Policy titled "Sterile Items" reviewed on 3/15/2016 at 1:00 PM directed "...All items are considered sterile unless opened, damaged, wet, or torn ..."

- Ultra Sound room (#'s 1, 2, and 3) observed on 3/14/2016 at 2:30 PM revealed one open and available for use Yankauer Suction tip (a device used to remove secretions by suction from a patients airway) with a package labeling the device as "...Sterile-For Single Use Only, Do not use if package is opened or damaged..."

Radiology Staff C interviewed on 3/14/2016 at 2:45 PM acknowledged the open and available for use Yankauer suction tips in three of three ultra sound rooms.

Policy titled "Fingernails and Hand Hygiene" reviewed on 3/15/2016 at 1:00 PM directed " ..Preform hand hygiene before coming on duty; before and after direct or indirect patient contact; before and after performing any bodily functions, such as blowing your nose or using the bathroom; before preparing or serving food; before preparing or administering medications; after direct or indirect patient contact with a patient ' s excretions, secretions, ir blood; and after completing your shift..."


- Registered Nurse Staff D observed on 3/14/2016 at 1:00 PM revealed Staff D exiting a patient room after providing patient care without performing hand hygiene.
Registered Nurse (director) Staff E interviewed on 3/14/2016 at 1:00 PM acknowledged RN Staff D's failed hand hygiene opportunity.

- Nurse Aide Staff F observed on 3/15/2016 at 4:45 PM revealed Staff F exiting a patient ' s room without preforming hand hygiene. Staff F proceeded to the nurses station counter and touching surfaces.
Infection Control Officer Staff G interviewed on 3/15/2016 at 4:45 PM acknowledged the failed hand hygiene opportunity immediately after exiting a patient care area.

- Nurse Aide Staff H observed on 3/15/2016 at 3:55PM exiting the room without performing hand hygiene and continued down the medical surgical areas hallway with the vitals machine. Staff H preformed hand hygiene prior to entering another patients room.

Infection Control Officer Staff G interviewed on 3/15/2016 at 3:56PM acknowledged Nurse Aide Staff H failed to perform hand hygiene immdeately after exiting a patient care area.

- Infection Control Officer Staff G interviewed on 3/10/2016 at 3:30 PM revealed they provide all staff with hand hygiene education and policies upon hire. Staff G indicated nursing receives monthly "hot topics" education that includes infection control.

Based on medical record review, policy review, and staff interview the facility failed to ensure that nursing services were provided that met the needs of 1 of 23 patients (Patient #1). The CAH failed to ensure that the facility's nursing staff adhered to the facility's policies/procedures regarding the care of patients with mental health conditions. The facility's nursing staff failed to ensure that a patient (Sample patient #1) was safely transported to an outside facility for treatment. The facility's nursing staff did not advocate for the patient when the emergency medical condition Patient #1 presented to the emergency department (ED) was not stabilized before local law enforcement arrested and removed him/her from the ED. This failure had the potential to place patients at risk for harming themselves or others.
Findings include:

- Patient #1's medical record reviewed on 3/9/2016 at 11:15 AM revealed the patient presented to the Emergency Department (ED) on 1/23/16 at 2:35 PM for "Suicidal Ideation" (thoughts of suicide). The attending physician's (Physician Staff A) History and Physical at 2:48 PM indicated Patient #1 had been released from the mental hospital last week with a diagnosis of bipolar disorder. Physician Staff K documented the patient had a history of suicidal ideation with a prior attempt. Psychiatric consult was conducted at 7:30 PM and a decision for involuntary admit to a mental health facility was made at that time. Physician Staff B orders revealed admission to observation status placed at 10:18 PM. Physician Staff B's documentation at 10:35 PM revealed the CAH ' s attempts to place the patient in an inpatient psychiatric facility were unsuccessful. and so patient #1 would be admitted to the CAH. Further, Physician Staff B ' s ED documentation revealed the patient had become "belligerent verbally abusive threatening there is no security here to watch patient one on one he is under arrest and will go to jail he is medically stable." Patient #1 was discharged in police custody at 11:39 PM without having their emergency psychiatric condition stabilized.
Physician Staff B interviewed 3/10/2016 between 9:00 AM and 9:30 AM acknowledged when they documented the patient was medically stable in the medical record they were not concluding the patient was psychiatrically stable. Staff B indicated an individual presenting to the ED with acute psychiatric symptoms was having an emergency medical condition (EMC). Staff B acknowledged Patient #1 was in fact not stable for discharge or transfer at the time they were arrested and allowed to leave with the police officers.

RN Staff J's notes reviewed on 3/9/2016 at 1:40 PM revealed at 6:09 PM patient #1 had a Xanax on the counter and was seen snorting the crushed Xanax. Staff J noted both Physician staff K and Physician Staff B agreed involuntary admission was necessary. At 6:43 PM patient #1 states, "I'm going to try to hang myself at this hospital too." At 10:34 PM, notes indicate patient #1 is to be a 1:1 observation and notification to security of the need for assistance was made. At 11:07 PM, patient #3 and an officer were having a confrontation, patient requesting officer slam their head into the ground to break their nose. At 11:23 PM, Officers inform nurse they are unable to sit with patient #1 due to staffing issues and indicated they could possible arrest the patient for disorderly conduct. At 11:45 PM, the patient was placed in handcuffs and escorted out of the ED with three officers at their side. RN Staff J acknowledged they did not feel jail is a safe disposition for a patient with an EMC that has not been stabilized and Patient #1 was not psychiatrically stable at the time they left with police. RN Staff J confirmed they contacted the CNO/COO Staff I prior to Patient #1's discharge. Staff J indicated that Staff I agreed with the discharge. Staff J failed to advocate for their patient and ensure stabilizing treatment was provided prior to discharging Patient #1.The medical record revealed Staff J failed to follow the CAH's policy and request further documentation from the Physician Staff B that Patient #1 was stable for discharge.

Mental Health Worker Staff N interviewed on 3/10/2016 between 10:25 AM and 10:55 AM indicated they performed a mental health-screening exam at about 4:35 PM on 1/23/2016. Staff N reported patient #1 became was very aggressive and started looking for places that would accept them as a patient, but was unable to secure a bed until Monday. Staff N agreed the patient was not safe for discharge and left the facility after Physician Staff B made the decision to place patient #1 in observation until a bed became available. Staff N revealed a police officer called and asked if the patient had been aggressive toward him/her. Staff N stated patient #1 had been and was informed they were arresting the patient and taking them to jail. Staff N reported patient #1 needed to be in a safe environment and felt the observation unit may have given him/her the opportunity to self-harm or harm others. Staff N indicated they did not feel this was a bad decision.

Administrative (CNO) Staff I interviewed on 3/10/2016 between 11:15 AM and 12:00 PM indicated they were called by RN Staff J while Patient #1 was being seen in the ED. Staff I acknowledged they agreed with the plan of care to admit Patient #1 to observation until a mental health facility bed became available. Staff I indicated later in the evening RN Staff J notified them in the change of plan to have Patient #1 arrested and taken to jail. Staff I indicated they agreed with this plan after receiving report the patient was combative and failed to follow direction by the police officers in the ED. Staff J acknowledged they has been informed the patient was medically cleared but knew the patients psychiatric EMC had not been stabilized. Staff I admitted "technically no (patient #1) should not have been discharged" . Staff I failed to advocate for a patient being treated in the ED after being notified of the intent to discharge an unstable patient to jail. Staff I failed to follow CAH policy and ensure that a patient's psychiatric emergency medical condition was stabilized prior to transfer or discharge.

CEO Staff L interviewed on 3/16/2016 between 8:05 AM and 8:20 Am indicated that they had no knowledge of the incident prior to this survey. Staff L acknowledged after briefly reviewing the incident they agree "we did the wrong thing" by allowing a patient with an emergency medical condition to be discharged prior to providing stabilizing treatment. Staff L indicated the nursing staff followed their chain of command and mental health policy by notifying the CNO/COO of the potential discharge. However, the discharge was allowed to proceed prior to stabilization and against their EMTALA policy.

Registered Nurse Staff M (ED Director) interviewed on 3/11/2016 between 8:30 AM and 9:30 AM revealed the RN staff has Mental Health patient packets with a checklist to help them with this patient population. A document within the packet titled " Behavior Health Patient Discharge Criteria" directs "...Continued status is necessary until all of the following are met: Risk Status Absence of thought of suicide, homicide, or serious harm to self or another ..." and ... "if documentation does not support "stable for discharge" the primary nurse will be directed to communicate the need for further documentation to the ED physician and/or primary care physician.

- Policy titled "Treatment and Referral of Emotionally Ill or Chemically Dependent Patients" reviewed on 3/14/2016 at 2:45 PM directed "... (the CAH) does not have the capabilities to provide inpatient psychiatric or substance abuse treatment services. Patients presenting to (the CAH's) emergency department (ED) with symptoms of psychiatric or substance abuse conditions will be provided a medical screening exam (MSE) to determine whether an emergency medical condition (EMC) exists, in accordance with the EMTALA policy .... And ... Mental Health Center AA provides on call professional services for patients in need of psychiatric or substance abuse assistance, and may be requested to assist in providing a MAE to determine whether a "Psychiatric or Substance Abuse EMC" exists. If such an EMC exists, then it is the policy of (the CAH) to provide stabilizing treatment until the EMC is "Stabilized," or if (the CAH) does not have the capabilities to stabilize such EMC, to effect an appropriate transfer of the patient to another facility for further stabilizing treatment in accordance with the EMTALA Policy.