HospitalInspections.org

Based on interview, policy review, contract review, and clinical record review, the facility failed to meet its requirement to provide stabilizing, emergency treatment to Patients #10, #14, and #20 prior to their discharge and Patients #12 and #21 prior to their transfer to another facility. The facility failed to execute an appropriate transfer for Patients #12 and #21. The sample size was 21 patients and the facility's census was 82 patients.
Findings include:
See A2407 regarding stabilizing treatment and A2409 regarding appropriate transfer.
These findings substantiate Complaint Number OH00063882.

Based on interview, policy review, review of a contract between the facility and a community mental health agency, and clinical record review, the facility failed to provide stabilizing treatment for psychological behaviors for Patients #10, #14, and #20 prior to their discharge and for Patients #12 and #21 prior to their transfer to another facility. This has the potential to affect all patients who come to the emergency department for emergency psychiatric treatment. The sample size was 21 patients and the facility's census was 82 patients.
Findings include:
Review of the facility's policy entitled Emergency Medical Treatment and Active Labor Act - Medical Screening was completed on 01/10/12. (The policy did not have a number, issue date, or approval date.) The policy stated psychiatric disturbances and/or symptoms of substance abuse are emergency medical conditions.
Review of the facility's policy number 2.49.2, "Emergency Screening, Stabilization and Transfer," was completed on 01/10/12. (The policy did not have an issue date or approval date.) The policy stated if the physician on duty decides the patient does not have an emergency medical condition, "the basis for this determination shall be fully and clearly documented in the medical record." A determination of whether Patients #10, #14, and #20, prior to their discharge or Patients #12 and #21, prior to their transfer to another facility still had an emergency medical condition was not documented clearly and fully in the clinical records.
1. The clinical record review for Patient #10 was completed on 01/10/12. The clinical record review revealed this 23-year-old patient presented to the emergency department as a walk-in on 12/13/11 at 1:51 P.M. with a chief complaint of heroin withdrawal, having last used on 12/12/11. Review of the nursing triage documentation revealed the patient was triaged at 1:55 P.M., with complaints that included, but not limited to, suicidal thoughts and general body aches/ headache with a pain level of 10/10 and 10 being the worst.
Further review of the clinical record for Patient #10 revealed the physician's exam identified the patient as alert, anxious, depressed mood, and tearful. The portion of the physical exam form which contains a box to check if the physician reviewed the nursing assessment was not checked, therefore there was no evidence that the physician was aware of the suicidal thoughts documented by the nurse during triage.
The patient was medicated with medications for nausea at 2:25 P.M., pain at 2:38 P.M., and then discharged home at 4:02 P.M. with a pain scale of 9/10 and a prescription medication for nausea. There was no documentation that the patient's psychological issues were addressed. The clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to the patient's psychological stability.
2. The clinical record review for Patient #20 was completed on 01/10/12. The clinical record revealed the patient was brought to the emergency department by a parent on 12/19/11 at 1:05 P.M. with a chief complaint of depression and self-injury evidenced by three cuts to the wrist. The emergency physician record dated 12/19/11 at 1:55 P.M. stated that the patient said he/she cut himself to relieve stress. The clinical record revealed the physician did order a psychological evaluation; however, there was no documentation that the psychological evaluation was completed or an assessment of the cuts to the wrists.
Further review of the clinical record revealed that the patient was discharged on 12/19/11 at 2:00 P.M. with instructions to return to the emergency department if he/she wanted to hurt themselves. The discharge instructions did not address the cuts to the wrist.
The clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being discharged.
3. The clinical record review for Patient #21 was completed on 01/10/12. The clinical record revealed a nursing data base that stated the 18-year-old patient was brought to the emergency department by police on 12/08/11 at 8:45 A.M. with a chief complaint of suicidal thoughts and agitation.
The clinical record further revealed an application for emergency (involuntary) admission, signed by the police, dated 12/08/11 that stated the patient attempted to cut self with kitchen knife. The application for emergency (involuntary) admission stated the patient asked to be shot in the head, and also said he/she should have just hung himself.
In addition, the clinical record revealed a physician's order for a psychological evaluation; however, there was no documentation a psychological evaluation was completed. A physician's order was in place dated 12/08/11 at 3:00 P.M. to transfer the patient at stated the patient to a local children's hospital.
The clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being transferred.
4. The clinical record review for Patient #14 was completed on 01/10/12. The clinical record revealed the 51-year-old was brought to the emergency department via emergency medical services on 12/15/11 at 11:00 P.M. with a chief complaint of being sad and depressed. The clinical record revealed a nursing note dated 12/15/11 at 11:00 P.M. that stated the patient had called the crisis intervention line due to feeling depressed over the loss of his/her mother. The triage note of the same time and date stated he/she had a pain level of 10/10 with 10 being the worst. Further review of the clinical record revealed one physician's order which was to administer five milligrams of Valium, which was documented as administered at 11:38 P.M.
Further review of the clinical record revealed discharge instructions that stated the patient was discharged home on 12/15/11 at 11:43 P.M. and an emergency physician record that stated the patient was given a prescription for 12 pain pills. The clinical record review revealed a nursing note at 11:43 P.M. that stated the patient's pain level continued to be a 10/10 at discharge.
The clinical record as a whole lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being discharged.
5. The clinical record review for Patient #12 was completed on 01/10/12. The patient was brought to the emergency department on 12/15/11 at 2:09 P.M. by police with a chief complaint of threatening to jump off a bridge. The clinical record revealed an emergency physician record dated 12/15/11 that stated the patient told his/her parent that he/she might jump off a bridge or cut his/her wrists. The clinical record revealed an order for a psychological evaluation; however, there was no documentation a psychological evaluation was completed. Further review of the clinical record revealed an application for emergency (involuntary) admission to a psychiatric facility. The clinical record also revealed a nursing database note that stated the patient left the emergency department for admission to another hospital at 12:15 P.M.
The clinical record revealed no documentation on the emergency physician record as to whether the patient's condition was unchanged, stable, or improved. In addition, the clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being transferred.
On 01/04/11 at 10:00 A.M. in an interview, Nursing Administrator #1 said the facility did not have any in-patient psychiatric units or any in-house psychiatry. He/she said the facility relies on a community mental health agency to make psychiatric assessments and placements as needed. He/she said the community mental health agency was available to come to the emergency department 24 hours a day, seven days a week.
Review of the contract between the facility and the community mental health agency, signed on 11/01/11, stated, "Company will furnish qualified mental health care professionals ... to provide psychiatric emergency care at Hospital on a twenty-four hour per day, three hundred sixty-five (365) days a year basis. Such psychiatric emergency care shall include Mental Health Pre-Screening and/or Crisis Intervention Services ...".
In an interview on 1/10/12 at 12:10 P.M., the above record review findings were presented to the Chief Nursing Officer, Nursing Administrator #1, and Quality Officer #1.
Patients #12, #20, and #21 had a physician's order for a psychiatric evaluation, and did not receive an evaluation. Patients #10 and #14 presented to the emergency department with psychiatric complaints, but did not have an order for a psychiatric evaluation and did not receive one.
On 01/10/12 at 12:10 P.M. in an interview, the Chief Nursing Officer said they did not have a policy that dictated when or how the emergency department was to utilize the community mental health agency and that when or how to utilize the community mental health agency was physician driven.
On 01/10/12 the facility presented results of emergency department chart audits for 08/11, 10/11, and 11/11. The results of the audit had not been finalized. The surveyor tabulated that 29 emergency department records lacked decision making/justification related to actions documented in the progress notes. The total emergency department records sampled was 94. Therefore, 30 percent of the audited charts lacked documentation of decision making/justification related to actions taken.
On 01/10/12 at 12:10 P.M. in an interview, Quality Officer #1 stated the results of the emergency department chart audits had not been tabulated and therefore had not been presented to any quality improvement committee. He/she said the auditing was something that had just been initiated.
This substantiates Complaint Number OH00063882.

Based on interview, policy review, contract review, and clinical record review, the facility failed to provide psychiatric treatment that was within its capacity for Patients #12 and #21 prior to their transfer. The facility also failed to have written physician certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate treatment at another facility outweigh the increased risks to the individual there would be medical benefits reasonably expected from treatment at another facility from being transferred and failed to summarize the benefits and risks of the transfer for Patients #12 and #21 . The sample size was 21 patients and the facility's census was 82 patients.
Findings include:
1. The clinical record review for Patient #12 was completed on 01/10/12. The patient was brought to the emergency department on 12/15/11 at 2:09 P.M. by police with a chief complaint of threatening to jump off a bridge. The clinical record revealed an emergency physician record dated 12/15/11 that stated the patient told his/her parent that he/she might jump off a bridge or cut his/her wrists. The clinical record revealed an order for a psychological evaluation; however, there was no documentation a psychological evaluation was completed. Further review of the clinical record revealed an application for emergency (involuntary) admission to a psychiatric facility. The clinical record also revealed a nursing database note that stated the patient left the emergency department for admission to another hospital at 12:15 P.M.
The clinical record revealed no documentation on the emergency physician record as to whether the patient's condition was unchanged, stable, or improved. In addition, the clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being transferred.
2. The clinical record review for Patient #21 was completed on 01/10/12. The clinical record revealed a nursing data base that stated the 18-year-old patient was brought to the emergency department by police on 12/08/11 at 8:45 A.M. with a chief complaint of suicidal thoughts and agitation.
The clinical record further revealed an application for emergency (involuntary) admission, signed by the police, dated 12/08/11 that stated the patient attempted to cut self with kitchen knife. The application for emergency (involuntary) admission stated the patient asked to be shot in the head, and also said he/she should have just hung himself.
In addition, the clinical record revealed a physician's order for a psychological evaluation; however, there was no documentation a psychological evaluation was completed. A physician's order was in place dated 12/08/11 at 3:00 P.M. to transfer the patient at stated the patient to a local children's hospital.
The clinical record lacked evidence of the physician's decision making/justification/stabilizing treatment related to whether the patient was psychologically stable prior to being transferred. The clinical record did reveal physician transfer orders; however, there was no documentation that the benefits and risks of transfer were explained to the patient.
Review of the facility's emergency transport policy (Section II, A 4.0) (the policy did not have an issue date or approval date) revealed that for both emergency and non-emergency transports, the physician must complete the physician transfer order form. A copy of the physician transfer order form was included in the policy. The form has a section for the physician to complete that stated the benefits and risks of transfer were explained to the patient.
Patient #12 did not have a form in the clinical record that explained the benefits reasonably expected from treatment at another medical facility outweighed the increased risks to the individual from being transferred, and Patient #21 had the physician transfer order form, but the section that stated the benefits and risks of transfer were explained to the patient was not completed.
On 01/04/11 at 10:00 A.M. in an interview, Nursing Administrator #1 said the facility did not have any in-patient psychiatric units or any in-house psychiatry. He/she said the facility relies on a community mental health agency to make psychiatric assessments and placements as needed. He/she said the community mental health agency was available to come to the emergency department 24 hours a day, seven days a week.
Review of the contract between the facility and the community mental health agency, signed on 11/01/11, stated, "Company will furnish qualified mental health care professionals ... to provide psychiatric emergency care at Hospital on a twenty-four hour per day, three hundred sixty-five (365) days a year basis. Such psychiatric emergency care shall include Mental Health Pre-Screening and/or Crisis Intervention Services ...".
Patients #12 and #21 had a physician's order for a psychiatric evaluation; however there was documentation that an evaluation was completed (or treatment) prior to their transfer.
In an interview on 1/10/12 at 12:10 P.M., the above record review findings were presented to the Chief Nursing Officer, Nursing Administrator #1, and Quality Officer #1.
This substantiates Complaint Number OH00063882.