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Based on observation, interviews, clinical record review, hospital document review and the course of an investigation, hospital staff failed to a) assess and treat pain, b) monitor a psychiatric patient for medical complications, c) document the type of support/treatment required during transfer and d) send all medical records related to the emergency medical condition to the receiving hospital. For one (1) of five (5) patient's with psychiatric conditions transferred to other hospitals. (Patient #16)

The findings include:

EMS was dispatched to the patient's home at 12:40 PM on 9/24/21 for reports of a fall. Patient #16 was reported to be alert and oriented upon arrival of EMS (emergency medical services) personnel. EMS examination found the left shoulder purple, bruised, with severe swelling and ecchymosis, multiple blisters on toes and fingers and 2 small lacerations on the patient's back. Patient #16 was able to move all extremities except the left shoulder which was swollen and deformed. EMS documented the patient denied pain until the left arm was moved, the patient reported pain 8 of 10 with movement. Patient #16's vital signs were documented as: blood pressure- 194/99, 189/114, 170/109; pulse- 87 bpm, 94 bpm, 97 bpm. Oxygen saturation and respirations were within normal limits. EMS reported patient's blood glucose level at 176 prior to arrival to the Emergency Room.

Nursing notes by Staff #5 documented Patient #16 arrival to the Emergency Room (ER) and first assessesment at 2 PM on 9/24/21. Assessment of the injury found bright red bruising on the front side of the left upper chest, front and back side of the left shoulder. A bony deformity was noted on the front and back side of left shoulder. The patient reported pain in left arm 10 of 10 on the pain scale. At 5:16 PM, Staff #5 noted the patient "having a conversation with someone who is not in the room. PT is jumping back and forth in the conversation and does not make any sense at this time."

On 9/24/21 at 5:57 PM, Physician #1 documented speaking with a family member who found the patient. The family member stated Patient #16 had a history of schizophrenia, had been admitted to this hospital before, had not been taking medications for months and cannot care for themselves.

On 9/24/21 at 2:02 PM, Physician #1 documented initiation of the medical screening exam (MSE). Physician #1 assessed Patient #16 and at 6:03 PM, documented the following: "Constitutional: This is a well developed, well nourished patient who is awake, alert, and in no acute distress. Cardiovascular: Regular rate and rhythm with a normal S1 and S2. No gallops, murmurs, or rubs. Normal PMI, no JVD. No pulse deficits. Respiratory: Lungs have equal breath sounds bilaterally, clear to auscultation and percussion. No rales, rhonchi or wheezes noted. No increased work of breathing, no retractions or nasal flaring, Abdomen/GI: Soft, non-tender, with normal bowel sounds. No distension or tympany. No guarding or rebound. No evidence of tenderness throughout. Back: no spinal tenderness. No costovertebral tenderness. Full range of motion. Musculoskeletal/extremity: Left shoulder with significant soft tissue swelling, and hematoma to the anterior chest wall, pain on moving the shoulder at all, 2+ pulses distally, normal sensation."

On 9/24/21 at 6:12 PM, Physician #1 documented Patient #16 was "found to have a displaced left humeral neck fracture, which was placed in a sling, patient needs orthopedic follow-up for that. CT of the chest shows right renal cell carcinoma with pulmonary metastases, apparently this renal mass was seen on abdominal ultrasound in 2018, however when asked the patient or (family member) this, and they say they have never been told previously that (Patient #16) had cancer. At this time patient is hemodynamically stable, hypertension which was helped with IV antihypertensive, patient has not been on any of (patient's) meds recently. Patient is not able to take care of (self), is talking to (self) in the room, seems to be thinking about past memories and perserverating about them, is denying to me any suicidal or homicidal ideation. But patient is not safe to be discharged home, (patient) has no family in the area to take care of (patient), (child) lives in Georgia." Physician #1 also documented Patient #16 "needs to be admitted medically for placement in a skilled nursing facility or admitted to a psychiatric facility".

Review of the clinical record found Patient #16 was not administered any pain medication when reporting pain on admission. The clinical record failed to provide any evidence of pain assessment or managment by physician(s) and/or nurse(s) during the 4 days Patient #16 was held in the ER waiting for placement in a psychiatric facility.

Review of hospital policy titled Pain Management - SOVAH Health, revised 8/2019 read in part as follows: "G. Ongoing assessments will occur throughout the hospital stay and are a routine part of the shift assessment. Physiological and Behavioral signs of pain will be considered in addition to the patient's report of discomfort."

The clinical record failed to provide documentation of reassessment of the neurovascular condition of Patient #16's left arm by physician(s) and/or nurse(s) until 9/28/21 at 8:00 AM, when NP #2 documented "(the patient) Distally neurovascularly intact". On the afternoon of 11/08/21, the surveyor interviewed three physicians and a Nurse Practitioner (Physicians #1, #2, #3 and NP #2) involved in the care of Patient #16. The providers agreed that initially this type of fracture could be very painful prior to initial treatment. The providers all agreed the usual initial treatment for a displaced left humeral neck fracture (if neurovascularly intact) was to immobilize the injury by placing the injured arm in a sling, provide pain control and discharge the patient for orthopedic follow-up as an outpatient. NP #2 stated that if the patient had neurovascular compromise with the fracture and needed intervention the patient would have been transferred to a hospital with orthopaedic capabilities. Without ongoing assessment (of a patient that could not self report) providers would not be aware if compromise had occurred . Additionally the providers all agreed, the situation is more complicated when the patient has psychiatric issues that may effect compliance. The patient may be unable to comprehend the need to protect against further injury by the use of a sling for the injured arm. During an interview, in the morning of 11/9/21, Staff #4 stated the patient didn't want to wear the sling even after the need for the sling was reinforced with the patient. The surveyor was unable to find mention of a "sling" in the clinical record other than as noted by Physicia #1 on 9/24/21 at 6:12 PM. Patient #16 was determined to be unable to provide care for themselve and would need to be monitored for decreased circulation and sensation in the injured extremity. Staff #3, (ER Director) was asked what the expectation would be for neurovascular assessments of the injury and replied "once a shift, at least". The assessment would not need to be a physicians' order but nursing judgement for standard care. Staff #3, stated behavioral health patients should be re-assessed each shift for suicide risk using the "Columbia-Suicide Severity Rating Scale". Staff #3 was asked about reassessment of medical issues the patient may have and replied that after the first two hours the patient should be assessed at least every shift. The clinical record failed to provide evidence of a reassessment of the patient's physical condition except as noted above and no documentation of a reassessment of suicidal ideation.

On 9/25/21 at 0:01 AM, Physician #2 documented the patient was evaluated by Psychiatry, who will take out an ECO (emergency custody order). Per this note Patient #16 "medically cleared at this time and awaiting placement..... Special discussion: This patient has been screened for obvious, acute medical emergencies. None were identified. The patient is being admitted for inpatient psychiatric evaluation and treatment."

Hospital staff failed to monitor blood glucose levels in a known diabetic patient. As noted above, EMS reported patient's finger stick blood glucose level at 176 prior to arrival to ER. Laboratory glucose level on 9/24/21 at 3:12 PM was 162 (normal 74-106) and on 9/27/21 was 124. The patient has a history of known IDDM (Insulin-dependent diabetes mellitus) documented by PA #1 on 9/25/21 at 8:50 AM. Review of outpatient prescriptions for the patient ordered by NP #1 on 8/10/20 found the patient had been prescribed Glucotrol XL 10 mg daily and Januvia 100 mg daily (oral medications for diabetes). A family member stated the patient had not been taking their "meds for months", it is unclear from the documentation which medications the family member was referring to. No orders for routine or prn blood glucose reading and/or glucose managment were found.

Review of EMTALA transfer record found the certifying physician failed to document on the transfer form, the type of support/treatment required during transfer and that all available medical records accompanied the patient. The clinical record failed to provide evidence of the information given to the accepting physician related to the patient #16's medical needs.

Review of hospital policy titled EMTALA - Medical Screening and Treatment of Emergency Medical Conditions, reviewed 8/29/20 read in part as follows: "L. Medical Screening Examination . . . A Medical Screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until the patient is either stabilized or appropriately transferred."

Review of hospital policy titled EMTALA - Transfer Policy, reviewed 8/29/20 found the following in part under procedure: "3.c. The transferring hospital must send copies of all available medical records pertaining to the individual's emergency condition to the hospital where the patient is being transferred." and "d. ...The physician at the sending hospital has the responsibility of determining the appropriate mode, equipment and attendants for the transfer."

The patient was documented by hospital staff to be medically cleared on 9/25/21 at 00:01 AM and a psychiatric admission was sought. After that time, there was no documentation of medical assessments or treatment during the patient's extended stay in the ER while awaiting placement. The patient initially presented with injuries from a fall. The patient had acute and chronic medical needs including a comminuted humeral neck fracture, IDDM, hypertension and renal carcinoma with pulmonary metastasis. On 9/28/21, a hearing was held to obtain a TDO (temporary detention order) for Patient #16. It was determined Patient #16 would be transferred to Catawba Psychiatric Hospital. At 2:57 PM on 9/28/21, Patient #16 left the ER by ambulance after a 4 day stay in the ER awaiting placement.

The above findings were shared with Staff #1, #2 and #3 at the time of discovery and with the management team at exit on 11/9/21 at 1:00 PM.