HospitalInspections.org

.
Based on interview and document review, the hospital's governing body failed to adopt written policies and procedures for the management of medical emergencies as evidenced by incomplete documentation for emergent care and quality monitoring in 5 of 10 patients reviewed (Patients #1406, #1407, #1408, #1409, and #1410).

Failure to adopt policies and procedures for the management of medical emergencies resulted in an unsafe environment for patients.

Findings included:

1. The hospital policy and procedure titled "Emergency Medical Screening," reviewed 07/20, showed that if an emergency condition is identified, the nurse will direct staff to call 911. Once the transport is completed, the nurse supervisor will complete the Emergency Medical Treatment and Labor Act (EMTALA) log and an incident report.

2. The hospital policy and procedure titled "Medical Emergencies," reviewed 01/21, showed that once a medical emergency has been addressed, a Memorandum of Transfer will be completed. Further, if it's determined that the patient does not need emergency medical attention, they will receive recommendation to contact their primary care provider. An incident report is to be filed after any occurrence of unexpected illness or injury.

3. The hospital policy and procedure titled "South Sound Behavioral 9-1-1 EMS Response Procedure," implemented 12/21, showed that staff should have a copy of the medical record prepared for emergency medical services (EMS) when they arrive.

During review of events that required the hospital to activate their rapid or emergency response from 01/01/22 to 01/31/22, Investigators #11 and #14 noted the following:

EMERGENCY RESPONSE #1

4. Patient #1407 was a 45-year-old female who presented for medical care at South Sound Behavioral Hospital on 01/08/22. On 01/08/22 at 12:51 PM, an unknown staff member called 911 from the hospital to request transport for Patient #1407. The staff member reported that they did not have beds for this patient and the patient needed to be transported to the hospital.

a. On 02/01/22, Investigators #11 and #14 reviewed the incident reports, memorandum of transfer, EMTALA, and phone logs. Documentation of a patient meeting Patient #1407's description could not be found.

b. On 02/17/22 at 4:00 PM, Investigator #14 interviewed an EMS staff member (Staff #1420). Staff #1420 confirmed that he responded to the 911 call at the hospital on 01/08/22 at 12:51 AM. He also reported that Patient #1407 appeared very emotional but had no medical need for transport. The patient declined further evaluation or transport from EMS and drove herself to the hospital for assistance.

c. On 02/01/22 at 11:15 AM, Investigators #11 and #14 interviewed the Chief Nursing Officer (CNO) (Staff #1404). Staff #1404 confirmed that there was no documentation of a 911 call or patient presenting for treatment on 01/08/22 that met Patient #1407's description. Staff #1404 also verified that current policy was to enter an incident report if 911 is called.

EMERGENCY RESPONSE #2

5. Patient #1408 was a 30-year-old male who presented for medical care at South Sound Behavioral Hospital on 01/12/22. A staff member called 911 from patient intake to transport Patient #1408 to the hospital for shortness of breath.

a. On 02/01/22, Investigators #11 and #14 reviewed the incident reports, memorandums of transfer, and House Supervisor documentation. Hospital House Supervisor documentation showed that Patient #1408 was evaluated by a nurse and a provider was notified. The clinical staff made the decision to call 911 for transport. Documentation of an incident report or memorandum of transfer could not be found.

b. On 01/26/22 at 4:30 PM, Investigator #14 interviewed an EMS staff member (EMS Staff #1415) who responded to the 911 call regarding Patient #1408 on 01/12/22. EMS Staff #1415 confirmed that he responded to the hospital for a complaint of a patient with shortness of breath. The patient reported to him that he had chronic asthma and needed his inhaler. EMS Staff #1415 had the patient call a family member to bring his inhaler. The patient improved after using his inhaler and was subsequently admitted to South Sound Behavioral Hospital for mental health care.

c. On 02/01/22 at 11:15 AM, Investigators #11 and #14 interviewed the Chief Nursing Officer (CNO) (Staff #1404). Staff #1404 confirmed that there was no incident report or memorandum of transfer regarding Patient #1408's care. Staff #1404 also verified that current policy was to enter an incident report if 911 is called.

EMERGENCY RESPONSE #3

6. Patient #1409 was a 39-year-old male who presented for medical care at South Sound Behavioral Hospital on 01/26/22.

a. On 02/01/22, Investigators #11 and #14 reviewed the incident reports, memorandum of transfer, EMTALA, and phone logs. Documentation of a patient meeting Patient #1409's description could not be found.

b. On 01/27/22 at 10:00 AM, Investigator #14 interviewed an EMS staff member (EMS Staff #1414). Staff #1414 reported that they received a call for Patient #1409 on 01/26/22 at 8:32 PM. The hospital staff member reported that the patient went to intake for requesting medications for his mental breakdown. He then left intake and was pacing and yelling in the parking lot. Police and ambulance responded, and the patient was transported to the acute care hospital via private ambulance.

c. On 02/01/22 at 10:56 AM, Investigators #11 and #14 interviewed the Chief Nursing Officer (CNO) (Staff #1404). Staff #1404 confirmed that there was no incident report or memorandum of transfer regarding Patient #1409's care. Staff #1404 also verified that current policy was to enter an incident report if 911 is called.

EMERGENCY REPONSE #4

7. Patient #1406 presented to South Sound Behavioral Hospital on 01/27/22 with mental health concerns. The patient was in intake with a staff member who noticed that Patient #1406's eye had what appeared to be a blood clot in it. The staff member called 911 for assistance.

a. On 02/01/22, Investigators #11 and #14 reviewed the incident reports, memorandums of transfer, and House Supervisor documentation. Hospital House Supervisor documentation showed that Patient #1406 was evaluated by a nurse and a provider was notified. The clinical staff made the decision to call 911 for transport. Documentation of an incident report or memorandum of transfer could not be found.

b. On 01/28/22 at 9:18 AM, Investigator #14 interviewed an EMS staff member (EMS Staff #1416) who responded to the 911 call regarding Patient #1406 on 01/27/22. EMS Staff #1416 confirmed that he responded to the hospital for a complaint of a patient with a bloody eye. The patient declined ambulance transport and chose to check out and drive himself to get his eye evaluated.

c. On 02/01/22 at 11:15 AM, Investigators #11 and #14 interviewed the Chief Nursing Officer (CNO) (Staff #1404). Staff #1404 confirmed that there was no incident report or memorandum of transfer regarding Patient #1406's care. Staff #1404 also verified that current policy was to enter an incident report if 911 is called.

EMERGENCY RESPONSE #5

8. Patient #1410 was an inpatient at South Sound Behavioral Hospital on 01/27/22. Hospital staff called 911 when the involuntary patient refused her blood pressure medication and her blood pressure became unstable.

a. On 02/01/22, Investigators #11 and #14 reviewed the incident reports, memorandums of transfer, and House Supervisor documentation. Memorandum of transfer (MOT) documentation showed that Patient #1410 was evaluated by a nurse and a provider was notified. The clinical staff made the decision to call 911 for transport. The MOT documentation did not specify if the transfer policy and procedures were followed.

b. On 01/28/22 at 9:18 AM, Investigator #14 interviewed an EMS staff member (EMS Staff #1416) who responded to the 911 call regarding Patient #1410 on 01/27/22. EMS Staff #1416 confirmed that he responded to the hospital for a complaint of a patient with unstable blood pressure. EMS staff #1416 reported that he waited 12 minutes for the patient to be brought to intake for transport. EMS staff #1416 also reported that the copy of the medical record was not ready when the patient was brought to intake, which resulted in an additional delay in care.

c. On 01/26/22 at 9:52 AM, Investigators #11 and #14 interviewed the charge nurse (Staff #1410). Staff #1410 reported that stable or ambulatory patients were to be brought to intake to meet EMS crews with a copy of their medical record for transfer.
.