HospitalInspections.org

Based on policy review, medical record review, Lift ticket (outside transport service) review and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 30 sampled Emergency Department (ED) patients (Patient #12).

~ Cross refer to Medical Screening Exam - Tag A2406.

Based on policy review, medical record review, Lift ticket (outside transportation services) review, and staff interviews, the hospital failed to perform an appropriate medical screening examination within its capacity to determine if a patient that presented to the hospital's Dedicated Emergency Department (DED) with a chief complaint of "Psych Eval - feels off" had a medical emergency for one of 30 sampled patients, (Patient #12).

The findings included:

Review of the hospital's policy, "EMTALA (Emergency Medical Treatment and Labor Act): Treatment Of Patient's With Emergency Medical Conditions" revealed "... It is the policy ... that all of the following individuals presenting to a dedicated emergency department ..., including women in labor, be given an appropriate medical screening examination by a qualified medical person ... to determine if an emergency medical condition exists: *Individuals who request, or on whose behalf a request is made for, examination or treatment for a medical condition, or *If no such request is made, present with appearance or behavior sufficient to cause a prudent layperson observer to believe that the individual needs examination or treatment for a medical condition ... Procedure; A. Medical Screening Examination; 1. All individuals presenting to a dedicated emergency department ... of (Hospital Name) for examination or treatment, including minors without a parent and women in labor, shall be given an appropriate medical screening examination to determine if an emergency medical condition exists. The medical screening examination may include laboratory tests, radiology studies, or consultations, as appropriate ..."

Review of a closed DED medial record on 02/13/2024 for Patient #12 (Campus B) revealed a 66 -year-old female that presented to the DED on 07/28/2022 at 0251 with a chief complaint of "Psych Eval - feels off". Review of the ED Triage note at 0256 revealed "Patient call non emergency (sic) 911 that she need help, (sic) scared to be alone and not feeling safe and not sure if she will be harm to other people, (sic) extreme guilt and afraid of dying..She's (sic) feeling uneasy,hot flushes. (sic) Patient is seeing a psychiatrist in Monarch NC and she's taking lithium and risperidone. Patient (sic) traumatized seeing her neighbor committing suicide (sic) last fall of 2021. Patient is complaining of abdominal and back pain." The Nurses note at 0308 revealed "Patient is scared to die and no plan to self harm, feeling so confused." Review of the ED Care Timeline at 0310 revealed a "Richmond Agitation Assessment Scale (RASS): Anxious, apprehensive, but not aggressive." Patient #12 was assigned an acuity score of "2" (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Vital signs at 0310 revealed "... 0-10 Pain Scale: 5 (0 means no pain and 10 mean severe pain); ... Pain Type: Acute pain; Pain Location: Abdomen; Pain Frequency: Constant/continuous; Pain Onset: On-going" Review of the ED Care Timeline at 0326 revealed the "ED Disposition was set to Discharge." Review of the Provider note filed at 0326 revealed " ... 66 y.o. (year-old) female with past medical history anxiety, bipolar disorder, diabetes, hypertension, hyperlipidemia presenting to the emergency department brought in by law enforcement for evaluation after the patient called nonemergency 911 asking for help because she is scared to be alone at home. On initial presentation, patient well-appearing, awake alert oriented answering questions appropriately. Vital signs stable ... Overall, presentation consistent with an early cry for help. Patient does not meet IVC (involuntary commitment) criteria at this time. Based on my evaluation, no indication for emergent blood work or diagnostic imaging. Patient will need psychiatric crisis center. A Lyft ride was set up for the patient to go (Facility C). Patient verbalized understanding and agreement with the plan ... HPI (History Present Illness) ... Patient explains she is very anxious at home and is not feeling safe. Patient reports that she feels like something bad is going to happen to her because she has recently been masturbating and feels that that (sic) is a sin for which she is going to be punished for...Patient reports that she is had (sic) some intermittent lower abdominal and lower back pains that have been chronic in nature ..." Patient #12 was discharged from the DED at 0414.

Review of the Lift Ticket revealed Patient #12 was picked up from Campus B's ED on 07/28/2022 at 0414 and dropped off at the address of Facility C at 0425 (11 minutes after being picked up).

Interview on 02/14/2024 at 1225 with Director #2 revealed he was the Associate Director at (Facility C) during the time Patient #12 presented there. Interview revealed Director #2 currently (as of date of interview 02/14/2024) works at Hospital A and B. Patient #12 was in the ED at Hospital B during the time of their initial opening of Hospital B. Interview revealed "the only way" a patient would be evaluated for psych concern in the initial opening of Hospital B is if they met IVC criteria.

Interview on 02/14/2024 at 1649 with Medical Director #3 revealed Patient #12 went home from the ED and called her OBGYN Provider. Patient #12 reported a similar story about excessive masturbation at home. Then Patient #12 presented to (Facility C) via the Police. Interview revealed Patient #12 could understand instructions based on documentation. Interview revealed a Psych Consult would be ordered for a patient if it was determined or known someone was not safe, or if someone is actively suicidal, or the Provider cannot determine these. Less than 50% of patients who come in with a chief complaint of "Psych Eval" would see or get a consult" because they would not meet criteria when one would be ordered. Interview revealed Medical Director #3 had reviewed the medical record for Patient #12 and everything in the note says Patient #12 was "medically stable and Psychiatrically stable". Interview revealed it "doesn't make sense some of the documentation" and then to give a Lift ticket to (Facility C). Interview revealed like any patient you want immediate follow up so in this case, was expediting that follow up by providing her with a ride there.

Request on 02/14/2024 to interview Provider #4 revealed he was not available.

Complainant subject (Patient #12) Facility C visit:

Review of the closed medical record for Patient #12 revealed Patient #12 presented to Facility C on 07/28/2022 at 1034. Review of the ED Care Timeline revealed at 1035 "Arrival Complaint: assessment." Review of the Psychologist Provider note at 1045 revealed "The patient is a 66 y.o. female with a history of MDD (major depressive disorder), Bipolar Disorder I with Psychotic Features, and PTSD (post traumatic stress disorder), who presents voluntarily with (town initials) PD (police department). She called the crisis line this morning because she adamantly believes she has killed someone, despite the fact there is no evidence to support this belief (police have checked on neighbors, attempted to reassure her everyone is ok). Patient reports that she was at (Hospital B) last night for this but was discharged back to her provider, (Named). She reports having recent med (medication) change, from Abilify to Risperidone, however, she is very confused and can't remember if she is taking her medication, taking too much, or not taking enough. Patient's symptoms on presentation include: confusion, disorientation, tangential and illogical thinking, severe anxiety, mood lability, sleep and appetite disturbance. She is very tearful, explaining that she is having lots of difficulty with her memory lately. ... Clinical Summary: The patient is at acutely elevated risk of suicidal/dangerousness to others and further worsening of psychiatric condition. Plan/Disposition: Patient will be referred for an emergency psychiatric evaluation to determine appropriate level of care needed."

Review of the LCMHC (licensed clinical mental health counselor) note at 1230 revealed " ... 66 y.o. ... female with a history of bipolar disorder with psychosis who presents to CAS (certified addiction specialist) due to concerns over psychiatric decompensation. Patient has been experiencing worsening mood symptoms of psychosis including believing that she will die if she closes her eyes. Also believes that everyone around her knows that she is dying but no one will be honest enough to tell her. Patient also reports that she has murdered someone but cannot explain why. She reports not sleeping for the last several days due to being preoccupied about death. She has been eating poorly. She has not been caring for herself including medical conditions. Patient presents as extremely distraught and cried through the assessment. Patient is currently experiencing symptoms of hypomania. She endorses compulsive sexual behaviors (masturbation). The patient is experiencing a decompensation of mood symptoms without a clear precipitant. This decompensation is likely to continue without immediate intervention. At this time, the patient presents as acutely dangerous to herself and requires inpatient hospitalization for safety and stabilization. The patient is in an acute elevated risk of suicide/dangerousness to others and further worsening of psychiatric condition ... patient does meet North Carolina involuntary commitment criteria at this time."

In summary, Rex Hospital failed to provide an appropriate evaluation of Patient #12 who presented to the Emergency Department with evidence of bizarre and delusional thought processes with report of pain.