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Based on review of medical records, review of policies and procedures, and interviews with key staff on September 21 and 26, 2011, it was determined that the hospital staff failed to meet the emergency needs of patients in accordance with acceptable standard of practice.
Based on review of medical records, review of policies and procedures, and interviews with key staff on September 21 and 26, 2011, it was determined that St. Mary's Regional Medical Center (SMRMC) failed to complete an accurate, appropriate medical screening examination, even after the patient was under the care of several emergency physicians, which resulted in not identifying the patient ' s emergency medical condition and not providing stabilizing treatment for the patient's condition.

Findings include:

1. A review of Patient A ' s medical record revealed that he/she was brought to SMRMC ' s (Saint Mary ' s Regional Medical Center) ED by police for evaluation at 11:15 on September 9, 2011 for " throwing feces. " He/she was transferred to RPC (Riverview Psychiatric Center) on September 13, 2011 at 12:30. Patient A was in SMRMC ' s Emergency Department for approximately ninety-seven (97) hours.

2. SMRMC ' s hospital policy, " EMTALA Medical Screening Examination and Stabilization " states " Before any transfer may occur, the transferring hospital must first provide, within its capacity and capabilities, medical treatment to minimize the risk to the health of the individual or the unborn child. "

3. The Physician ' s " Emergency Department Provider Report " completed on September 9, 2011, records the " chief complaint of throwing feces. " In addition, under the section identified " History of Present Illness " it was documented " Quality of the problem is overwhelming; Region the problem is psychiatric; Severity is moderate; Onset/timing -acute; Context -unable to cope with psychiatric problem/psychosis; Modifying factors/psychosocial; Associated symptoms/insomnia. " There was no other history obtained or recorded.

4. In addition, the " Emergency Department Provider Report " under section " Physical Exam " completed by the initial emergency physician, documented that Patient A ' s eyes were " nonicteric. " However, during an interview with the physician on September 26, 2011, he reported that the patient had tape over an eye glass lens and that he never examined his/her eyes, nor did he inquire as to why the tape was there.

5. None of the emergency physicians, who were subsequently responsible for Patient A ' s care in the Emergency Department, recorded or performed an appropriate medical screening exam identifying the redness, dilated pupil and detached retina of the right eye. A review of ongoing physician care from September 9, 2011 to September 13, 2011 indicated the following sequence of events:

a. On September 9, 2011 at 16:00, the on-coming Emergency physician wrote, " The plan is for ongoing psychiatric evaluation for likely admission. "

b. On September 10, 2011 at 07:35, an Emergency physician documented, " care was assumed by me at midnight from doctor ....patient has not required any interventions from me during the course of my shift. "

c. On September 10, 2011 at 15:16, an Emergency physician documented " the patient was stable during my shift, care was signed over to doctor ... at change of shift. Continued plan to look for a bed. "

d. On September 10, 2011 at 19:21, a Psychiatric Nurse Practitioner documented, " the patient will remain here in Behavioral Emergency Department until an appropriate psychiatric bed is found [him/ her]. "

e. On September 10, 2011 at 23:43, an Emergency physician documented, " [She ' ll/He ' ll] be held in the ED over night and presented for involuntary admission on (sic) the morning. "

f. On September 11, 2011 at 7:28 am, the Emergency physician documented, " the patient did not require any acute intervention (sic) for me. "

g. On September 11, 2011 at 15:26, the Emergency physician documented, " there is no plan for placement for the patient at this time. Care was under productive. "

h. On September 11, 2011 at 19:16, the nurse practitioner documented, " No [male/female] beds available in the State of Maine. "

i. On September 11, 2011 at 20:31, the Emergency physician documented, " the patient improved in the emergency department, behavioral department, bed placement still pending. " In an interview with this emergency physician on September 26, 2011, he stated that he did not examine this patient through out the shift.

j. On September 12, 2011 at 19:18, the nurse practitioner documented, " the patient will be involuntarily admitted to the River View Psychiatric Facility tomorrow ' s date at 1300. "

k. On September 12, 2011 at 1:46 am, the Emergency physician documented, " the patient did not require any interventions for me (sic) during the course of my shift. " In an interview with this Emergency Physician on September 26, 2011, she stated " had not laid eyes on the patient. "

l. On September 12, 2011 at 10:07, the emergency physician documented, " No medical intervention was required for this patient. " In an interview with this physician on September 21, 2011, he stated that he had not seen the patient.

m. On September 13, 2011 at 2:32 am, the emergency physician documented, " evaluation by Crisis. "

n. On September 13, 2011 at 10:02, the emergency physician, who affected the transfer, documented that the patient was to be transferred. In an interview with this Emergency physician he stated that he never examined the patient.

o. On September 13, 2011, the nurse practitioner wrote that the patient was to be admitted at the Riverview Psychiatric Facility at 1300.

p. There was no documentation in the medical record that any of the emergency physicians contacted the on-call Ophthalmologists for a consult for Patient A.

6. During an interview with the Chief of Emergency Medicine at SMRMC on September 21, 2011, he stated that the emergency physicians are responsible for all of the emergency medical management of emergency patients. The emergency physician co-manages, but is ultimately responsible for the care of psychiatric patient in the Behavioral Emergency Department, working in tandem with the psychiatric nurse practitioners and supervising psychiatrist.

7. Upon arrival to the Riverview Psychiatric Center at 16:30, Patient A was seen by a physician who in his " History and Physical Exam " documented, " the patient wore taped glasses (right side ) the right eye is visibly red, the iris (sic, pupil) was dilated and very distorted, clearly needing immediate attention by eye specialist. "

8. An Ophthalmology consultation requested by RPC indicated that the patient had " no light perception vision in right eye. Has a dilated pupil in the right eye. He/She is " mildly injected with a retinal detachment. "

9. During an interview with the Chief of Emergency Medicine at SMRMC on September 21, 2011, he stated that the emergency physicians are responsible for all of the emergency medical management of emergency patients. The emergency physician co-manages, but is ultimately responsible for the care of psychiatric patient in the Behavioral Emergency Department, working in tandem with the psychiatric nurse practitioners and supervising psychiatrist.

10. On December 17, 2008, SMRMC ' s Certificate of Need (CON) was approved for a new Behavioral Emergency Department based upon their mission which states, " integration of services will lead to creative and comprehensive treatment plans for patients who frequently seek crisis services at St. Mary ' s with the goal of reducing future emergency department visits. This will lead to better care for all patients, and will allow the behavioral service to begin treating patients immediately upon arrival in the ED ... ... "

11. Review of Patient A ' s clinical record revealed that even after four days of being housed in the Behavioral Emergency Department, there was no documentation of a " creative and comprehensive treatment plan. " In addition, there was no documentation that SMRMC, which has an inpatient psychiatric unit, evaluated their capacity and capability to admit Patient A to their inpatient unit on a daily basis.

12. The medical record at RPC also documented that an emergency ophthalmic evaluation was completed on the Patient A and he/she was diagnosed with a detached retina. The RPH doctor documented that the patient had a " red eye (right) found to be trauma most likely with retinal detachment. Probably unable to be salvaged at this time, but steroids and a revisit to [Ophthalmologist] in two days might result in a more accurate prognosis. "



The cumulative effect of these deficient practices resulted in this Condition of Participation to be out of compliance.