HospitalInspections.org

Based on interview, the facility failed to ensure the confidentiality of patient records sent with police officers during a patient discharge for 1 of 30 sampled patients (#21).

Findings:

During an interview of the Risk Manager on 3/15/13 at 12:30 PM, she stated that after patient #1 left, the Chief Operating Officer (COO) spoke to the Emergency Room physician at South Seminole Hospital. During this conversation, it was learned that a nurse had sent information from the medical record which belonged to patient #21.

During an interview with the COO at 3 PM on 3/15/13, he confirmed that incorrect paperwork had been sent with the police.

During an interview of the Risk Manager on 3/15/13 at 4:15 PM, she confirmed the finding.

Based on interview and record review, the facility failed to ensure the direct transfer of patients and medical information to appropriate healthcare facilities for follow-up or ancillary care in the form of psychiatric services for 1 of 30 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. A nurse's note indicating occurrence at 9:14 AM on 2/28/13 read, "Pt (patient) arrived EMS (Emergency Medical Services)...." The patient was Baker Acted on 2/28/13 at 10 AM (per the Certificate of Professional Initiating Involuntary Examination). An Emergency Room physician note indicated that hospitalist physician #A returned his call at 11:55 AM on 2/28/13. He wrote, "Will see patient, agrees with eval, accepts admit."

Physician #A admitted the patient at 12:10 PM on 2/28/13 for medication overdose. Physician's order at this time read, "Admission...overdosage."

The History and Physical, dictated on 2/28/13 at 10:55 PM by physician #A read, "We will need psychiatric input. Possible discharge to an inpatient facility when medically cleared."

Physician #A's note signed at 12:57 PM on 3/01/13 read, "Plan: Pt. medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate." Physician #A's order on 3/01/13 at 2:31 PM read, "D/C (discharge) plan Elec (electronic) med (medication) rec (reconciliation) done." Physician #A's order on 3/1/13 at 2:34 PM read, "Discharge pt."

The Discharge Summary dictated on 3/04/13 at 7 AM by physician #B, read, "After he was medically cleared....I explained to the case managers and nursing staff that the patient should be discharged to a Psych Facility. Dr. (#C) from Psychiatry agreed with this as well." Case Management notes beginning on 3/01/13 at 5:59 PM, where efforts to secure a psychiatric facility transfer were documented, confirm an understanding of the physician's intention for discharge as mentioned in the Discharge Summary.

Psychiatrist #C's note on 3/01/13 at 11:16 PM read, "Diagnosis, Assessment & Plan ... Discharge planning: to psych, inpatient." Physician orders on 3/01/13 at 11:18 PM were for Ativan (Lorazepam) 2 mg (milligrams).

A nurse's note on 3/02/13 at 3 AM mentioned that the patient had become highly combative to the point that restraints were applied and the medication Geodon was ordered to be given.

Up to the time of this preceding note, and throughout the patient's entire stay, there was never a cancellation of the discharge order for a psychiatric facility of 3/01/13. However, the preceding report of combative patient behavior was followed by handwritten physician orders by physician #B on 3/02/13 at 5:59 AM which altered this understanding significantly, for it added a condition to continuing transfer attempts. It read, "If pt continues to be combative, D/C (discharge) to Police Dept." Physician #B's orders on 3/02/13 at 7 AM also read, "If pt continues to be combative OK to discharge to police department."

The nature of these 3/02/13 orders, which would be implemented if a behavior is exhibited, allowed the patient to stay in the facility if he was not combative, while efforts to secure a psychiatric facility discharge/transfer to obtain physician-mandated mental health treatment would move forward simultaneously. If, however, the patient was combative, the psychiatric facility discharge/transfer attempts under the orders of 3/01/13 would essentially be ignored per the new 3/02/13 orders. There was no assertion in the medical record at the time of this 3/02/13 order or at any later time that the patient was no longer in need of psychiatric treatment by a psychiatric facility. In fact, later text reveals that this need was still perceived by physicians. This meant that the patient still had not addressed or unresolved psychiatric treatment needs which required further treatment and they would actually not abate if a specified behavior was exhibited.

The effect of these orders, when they were issued, was that on any unknown future date after their issuance, the patient could be automatically discharged to a non-medical entity without a physician being apprised.

Physician #B's note on 3/02/13 at 7:18 AM read, "The patient had become very violent breaking things and swinging a walker and trying to break windows.... I explained to the nurse supervisor that she needed to call the police if she believed that she and other nurses were in danger.... Plan.... Pt medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate. Need to d/c to crisis center as soon as possible."

A nurse's note indicating occurrence on 3/02/13 at 11:09 PM read, "(psychiatrist #C) here, visits with pt and his father, medications increased. Pt took extra meds without difficulty." Psychiatrist #C's note on 3/02/13 at 10:47 PM read, "... plan increase Seroquel to 200 mg q hs (bedtime)."

The record revealed that for much of 3/02/13, there were continued unsuccessful attempts to transfer the patient to a psych facility.

Physician orders of 3/02/13 at 11:30 PM read, "Zyprexa 5 mg IM (intramuscular) prn (as needed) q8hr (every eight hours) prn agitation." Physician orders were issued at 11:23 PM on 3/2/13 for STAT (urgent) Zyprexa at 10 mg PO (by mouth). Physician orders for "Lorazepam inj (injection) 2 mg (milligrams)/1 ml (milliliter) vial (2 mg.)" were issued at 1:32 AM on 3/03/13 (not given).

Seroquel was given at 10:53 PM (again, an increased dose) on 3/02/13; PO Zyprexa was administered at 11:39 PM (the first time this medication was given). Lorazepam was administered at 3/02/13 at 10:17 PM (per the 3/1/12 orders) and also at 1:41 AM on 3/03/13 (per the orders of 1:32 AM on 3/03/13; the first time this medication was given at a close interval). The Lorazepam injection under the orders of 1:32 AM on 3/03/13 was given at 1:41 AM. Later text reveals that most of these medications were administered just a short time before the patient's departure (2:09 PM on 3/03/13).

A nurse's note indicating occurrence on 3/03/13 at 2:41 AM (after the patient discharge at 2:09 AM, see below) read, "12:00 AM - Pt (patient) given Lorazepam, Seroquel, Zyprexa to calm him (see administration times, above). Not effective. Pt's father at bedside, safety sitter, hospital security also at bedside holding pt to keep from harming himself. Soft wrist restraints on bil (bilateral) wrists to keep pt from harming himself. Dr. had already medically cleared pt yesterday (it was actually on 3/01/13 at 12:57 PM). Pt not reacting to meds and is extremely violent. Sanford Police called to help with violent pt who is discharged."

During an interview of physician #B on 3/15/13 at 12:15 PM, he concurred that the patient was in need of treatment at a psychiatric facility throughout his entire stay.

A review of a Security report revealed that the patient was "violent and combative" on 3/02/12 at 12:55 a.m. It read, "Patient was discharged over to SPD (Sanford Police Department). Patient was transported." The officer who wrote this report returned to his office at 2 PM.

A handwritten note from Sanford Police Department by a police officer, written at 2:06 AM on 3/03/13 read, "(Patient #1) was discharged to the Sanford Police Department, and it was our decision to take (patient #1) to South Seminole Hospital."

Discharge Instructions were printed on 3/03/13 at 2:09 AM read, "Discharge to police custody...." A nurse's note indicating occurrence on 3/03/13 at 2:46 AM read, "2:17 AM - Pt discharged to his father and Sanford Police due to violence and him not being able to be handled by his parents at home." There was no mention in this note of any post-facility treatment needs, despite the fact that the physicians had continuously voiced a need (see prior text) for the patient to be transferred to a psychiatric facility for further treatment.

Although the patient had combative behavior and had received new and increased dose medications just prior to departure, there was no evidence in the record of the physician having been notified of this automatic discharge at or before the time it took place and provided an opportunity to attest to whether medical stability still existed or issue any final orders if deemed necessary. There was no evidence in the medical record of pertinent documents from the medical record having been sent along with the patient at the time he departed the facility. There was no evidence of any consideration of the possible effect, while in police custody, of the new or increased dose medications which the patient was provided just prior to discharge. There was no evidence of any assurance being provided to the facility that the patient would have readily available medical attention (as found in health care transport), should a need arise, during the interim between his departure and any eventual acceptance into another health care facility. Since the police were not health care providers and there was no accepting facility, the standard practice of providing a report could not be effected. Through the implementation of the 3/02/13 order, the stated intent of the 3/01/13 order (discharge to a facility, not the police) was violated. This was an order which even the physician who entered the 3/02/13 order asserted on the same day as being in force.

The Discharge Summary on 3/04/13 at 7 AM by physician #B read, " Disposition: The patient was discharged to the care of the Sanford Police Department. After he was medically cleared, I explained to the case managers and nursing staff that the patient should be discharged to a Psych Facility. Psychiatrist #C agreed with this as well....On hospital day 3, the patient became unruly again, and police were called. They came and evaluated the patient, and took him to the South Seminole."

In summary, orders of 3/01/13 for a direct transfer of a patient and their corresponding medical information to a healthcare facility, through healthcare transport, was not effected as a result of the orders of 3/02/13. These latter 3/02/13 orders made no reference to follow-up healthcare and no supplemental evidence was available to assert otherwise with respect to their intent.

During an interview of the Risk Manager on 3/15/13 at 4:15 PM, she confirmed the findings.

Based on interview and record review, the facility failed to ensure the direct transfer of patients and medical information to appropriate healthcare facilities for follow-up or ancillary care in the form of psychiatric services for 1 of 30 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. A nurse's note indicating occurrence at 9:14 AM on 2/28/13 read, "Pt (patient) arrived EMS (Emergency Medical Services)...." The patient was Baker Acted on 2/28/13 at 10 AM (per the Certificate of Professional Initiating Involuntary Examination). An Emergency Room physician note indicated that hospitalist physician #A returned his call at 11:55 AM on 2/28/13. He wrote, "Will see patient, agrees with eval, accepts admit."

Physician #A admitted the patient at 12:10 PM on 2/28/13 for medication overdose. Physician's order at this time read, "Admission...overdosage."

The History and Physical, dictated on 2/28/13 at 10:55 PM by physician #A read, "We will need psychiatric input. Possible discharge to an inpatient facility when medically cleared."

Physician #A's note signed at 12:57 PM on 3/01/13 read, "Plan: Pt. medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate." Physician #A's order on 3/01/13 at 2:31 PM read, "D/C (discharge) plan Elec (electronic) med (medication) rec (reconciliation) done." Physician #A's order on 3/1/13 at 2:34 PM read, "Discharge pt."

The Discharge Summary dictated on 3/04/13 at 7 AM by physician #B, read, "After he was medically cleared....I explained to the case managers and nursing staff that the patient should be discharged to a Psych Facility. Dr. (#C) from Psychiatry agreed with this as well." Case Management notes beginning on 3/01/13 at 5:59 PM, where efforts to secure a psychiatric facility transfer were documented, confirm an understanding of the physician's intention for discharge as mentioned in the Discharge Summary.

Psychiatrist #C's note on 3/01/13 at 11:16 PM read, "Diagnosis, Assessment & Plan ... Discharge planning: to psych, inpatient." Physician orders on 3/01/13 at 11:18 PM were for Ativan (Lorazepam) 2 mg (milligrams).

A nurse's note on 3/02/13 at 3 AM mentioned that the patient had become highly combative to the point that restraints were applied and the medication Geodon was ordered to be given.

Up to the time of this preceding note, and throughout the patient's entire stay, there was never a cancellation of the discharge order for a psychiatric facility of 3/01/13. However, the preceding report of combative patient behavior was followed by handwritten physician orders by physician #B on 3/02/13 at 5:59 AM which altered this understanding significantly, for it added a condition to continuing transfer attempts. It read, "If pt continues to be combative, D/C (discharge) to Police Dept." Physician #B's orders on 3/02/13 at 7 AM also read, "If pt continues to be combative OK to discharge to police department."

The nature of these 3/02/13 orders, which would be implemented if a behavior is exhibited, allowed the patient to stay in the facility if he was not combative, while efforts to secure a psychiatric facility discharge/transfer to obtain physician-mandated mental health treatment would move forward simultaneously. If, however, the patient was combative, the psychiatric facility discharge/transfer attempts under the orders of 3/01/13 would essentially be ignored per the new 3/02/13 orders. There was no assertion in the medical record at the time of this 3/02/13 order or at any later time that the patient was no longer in need of psychiatric treatment by a psychiatric facility. In fact, later text reveals that this need was still perceived by physicians. This meant that the patient still had not addressed or unresolved psychiatric treatment needs which required further treatment and they would actually not abate if a specified behavior was exhibited.

The effect of these orders, when they were issued, was that on any unknown future date after their issuance, the patient could be automatically discharged to a non-medical entity without a physician being apprised.

Physician #B's note on 3/02/13 at 7:18 AM read, "The patient had become very violent breaking things and swinging a walker and trying to break windows.... I explained to the nurse supervisor that she needed to call the police if she believed that she and other nurses were in danger.... Plan.... Pt medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate. Need to d/c to crisis center as soon as possible."

A nurse's note indicating occurrence on 3/02/13 at 11:09 PM read, "(psychiatrist #C) here, visits with pt and his father, medications increased. Pt took extra meds without difficulty." Psychiatrist #C's note on 3/02/13 at 10:47 PM read, "... plan increase Seroquel to 200 mg q hs (bedtime)."

The record revealed that for much of 3/02/13, there were continued unsuccessful attempts to transfer the patient to a psych facility.

Physician orders of 3/02/13 at 11:30 PM read, "Zyprexa 5 mg IM (intramuscular) prn (as needed) q8hr (every eight hours) prn agitation." Physician orders were issued at 11:23 PM on 3/2/13 for STAT (urgent) Zyprexa at 10 mg PO (by mouth). Physician orders for "Lorazepam inj (injection) 2 mg (milligrams)/1 ml (milliliter) vial (2 mg.)" were issued at 1:32 AM on 3/03/13 (not given).

Seroquel was given at 10:53 PM (again, an increased dose) on 3/02/13; PO Zyprexa was administered at 11:39 PM (the first time this medication was given). Lorazepam was administered at 3/02/13 at 10:17 PM (per the 3/1/12 orders) and also at 1:41 AM on 3/03/13 (per the orders of 1:32 AM on 3/03/13; the first time this medication was given at a close interval). The Lorazepam injection under the orders of 1:32 AM on 3/03/13 was given at 1:41 AM. Later text reveals that most of these medications were administered just a short time before the patient's departure (2:09 PM on 3/03/13).

A nurse's note indicating occurrence on 3/03/13 at 2:41 AM (after the patient discharge at 2:09 AM, see below) read, "12:00 AM - Pt (patient) given Lorazepam, Seroquel, Zyprexa to calm him (see administration times, above). Not effective. Pt's father at bedside, safety sitter, hospital security also at bedside holding pt to keep from harming himself. Soft wrist restraints on bil (bilateral) wrists to keep pt from harming himself. Dr. had already medically cleared pt yesterday (it was actually on 3/01/13 at 12:57 PM). Pt not reacting to meds and is extremely violent. Sanford Police called to help with violent pt who is discharged."

During an interview of physician #B on 3/15/13 at 12:15 PM, he concurred that the patient was in need of treatment at a psychiatric facility throughout his entire stay.

A review of a Security report revealed that the patient was "violent and combative" on 3/02/12 at 12:55 a.m. It read, "Patient was discharged over to SPD (Sanford Police Department). Patient was transported." The officer who wrote this report returned to his office at 2 PM.

A handwritten note from Sanford Police Department by a police officer, written at 2:06 AM on 3/03/13 read, "(Patient #1) was discharged to the Sanford Police Department, and it was our decision to take (patient #1) to South Seminole Hospital."

Discharge Instructions were printed on 3/03/13 at 2:09 AM read, "Discharge to police custody...." A nurse's note indicating occurrence on 3/03/13 at 2:46 AM read, "2:17 AM - Pt discharged to his father and Sanford Police due to violence and him not being able to be handled by his parents at home." There was no mention in this note of any post-facility treatment needs, despite the fact that the physicians had continuously voiced a need (see prior text) for the patient to be transferred to a psychiatric facility for further treatment.

Although the patient had combative behavior and had received new and increased dose medications just prior to departure, there was no evidence in the record of the physician having been notified of this automatic discharge at or before the time it too