HospitalInspections.org

As a result of the investigation Floyd Medical Center was not in compliance with 42 CFR Parts 489.20 and 489.24, Responsibilities of Medicare Participating Hospital in Emergency Cases. The following deficiencies were cited:

1. Based on review of medical records, Emergency Department Security Form, facility's security contract, Surveyor notes, behavioral health unit bed census, policy/procedure, Emergency services patient care report and staff interviews, the hospital failed to provide a Mental Health Evaluation that was within the capability and capacity of the hospital for an individual with a 1013 (involuntary treatment) who became combative and was arrested in Floyd Medical Center Emergency Department (ED) for one (1) patient (#10) of the twenty (20) sampled patients. Refer to findings in tag A-2406.

2. Based on review of medical records, policies and procedures, on call schedules, behavioral health bed census report and interviews the facility failed to ensure that stabilizing treatment was provided as required that was within the capability and capacity of the hospital for one (1) patient (#10) for one of twenty sampled patients. Cross refer to Tag 2406 for additional information regarding patient #10. Refer to findings in tag A-2407.

Based on observation, staff interview, and review of facility policies, the facility failed to post conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX.

Findings include:

Observation on 2/10/2014 at 8:38 a.m. in the Emergency Room (ER) tour with the ER Manager and the ER Director, revealed at the ambulance, ambulation entrance, ER waiting room, and registration desk a posted notice, "Notice: This Facility is Legally Obligated to Serve the Community. This facility is not allowed to discriminate against a patient because of race, creed, color, national origin, or because a patient is covered by a program such as Medicaid or Medicare. If this facility provides emergency services it must not deny those services to a person who needs them but cannot pay for them. If you believe that you have been improperly denied services, contact the Admissions or Business Office of this facility or call Toll Free 1-800-368-1019 and TDD 1-800-537-7697 U.S. Department of Health and Human Services Office for Civil Rights."

Continued observation of the "Notice" revealed no evidence that the required specifications on the signage included the rights of individuals with respect to examination and treatment for an emergency medical condition. Interview with the ER (Emergency Room) Manager and ER Director revealed no knowledge that the MSE was required on the signage.

Review of facility policy AD-03-039, Respecting EMTALA (COBRA) Compliance, developed 12/90, last review date 2/02, last revision date 3/03, failed to reveal information which addressed posting of EMTALA required signage.

Based on review of medical records, Emergency Department Security Form, facility's security contract, Surveyor notes, behavioral health unit bed census, policy/procedure, Emergency services patient care report and staff interviews, the hospital failed to provide a Mental Health Evaluation that was within the capability and capacity of the hospital for an individual with a 1013 (involuntary treatment) who became combative and was arrested in Floyd Medical Center Emergency Department (ED) for one (1) patient (#10) of the twenty (20) sampled patients.

Findings include:


Review of facility policy AD-03-039, Respecting EMTALA (COBRA) Compliance, developed 12/90, last review date 2/02, last revision date 3/03, revealed in part, Policy: It is the of the Floyd Medical Center that all patients deemed to have an emergency medical condition shall either be: treated until stabilized or appropriately transferred...Emergency Medical Condition...1. A medical condition manifesting itself by acute symptoms of sufficient severity..such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient...in serious jeopardy..Process of Care: 1. Medical Screening Examination: if any individual comes to, or is brought to Floyd Medical Center and a request is made on the individual's behalf for examination or treatment for a medical examination, the Emergency Care Center (ECC) or appropriate personnel will provide for an appropriate medical screening examination for the individual within its capability (including all ancillary services routinely available to Floyd Medical (FMC) to determine if an emergency medical condition exists."


The facility's policy titled "Care of the Mental Health Patient" policy No:ECC 02-014, developed 3/00 last revised 01/12 was reviewed. the policy revealed in part, "Policy: to Provide guidelines for the guesting of medically stable Emergency Department patients with psychiatric..(..1013) in the Emergency Care Center to await final disposition. The Emergency Care Center provides the right personnel and environment for proper disposition of the patient... The Security Department shall abide by the policies formulated by the ECC department in this regard,since the patient is considered under the care of the clinical staff while in the ECC...Roles and Responsibilities:Mental Health Screener: Floyd Behavioral Health screeners work collaboratively with patient/family, clinical staff, ECC physician and Psychiatrist on call to appropriately and efficiently screen the Behavioral Health patient and determine appropriate treatment... Procedure Implementation: 6. Appropriate referrals may be made to a Psychiatrist. Medical Screeners are provided 24 hours/day by Behavioral mental health screeners...after appropriate screening and treatment."

Review of the policy titled, "Care of the Patient With Assaultive Behavior", Policy No: PCS-03-005, Review date 12/99, revised date 6/11, indicated in part, "Preparation For Physical Control of an Assaultive Patient": 1 Evaluate what will need to be accomplished and how may persons will be necessary to be successful. Call "Code Grey" giving the immediate location of the incident."


Review of the facility's contract with the security service revealed that it began
on 8/1/2013 for a term of three (3) years; that the service provided uniformed security services twenty-four (24) hours a day, seven (7) days a week; and, that security guard training included emergency preparedness, evacuation planning, accrediting agency compliance, bloodborne pathogens, fire safety, HIPAA, and, crisis intervention (is a training program developed to help police officers react appropriately to situations involving mental illness) .

The medical record from the transferring hospital dated 11/11/2013 for patient #10 was reviewed. The medical record revealed that patient #10, had been discharged from a behavioral health facility eleven (11) days earlier; had threatened to harm his/her parents; was alert, combative, and, disoriented. Patient #10 received Geodon (an antipsychotic used to treat schizophrenia) 20 milligrams (mg) via intramuscularly (I.M.) on 11/11/2013 at 5:12 p.m. Documentation by the ED physician revealed that patient #10 was hyperverbal (pressure of speech is a tendency to speak rapidly- difficult to interrupt), disoriented and combative. Further review indicated that patient #10 was accepted by a physician for transfer at Floyd Medical Center. Patient #10 ' s clinical Impression documented by the ED physician was Schizophrenia with Psychosis and Homicidal Ideation towards his father. The ED physician also completed a 1013 Form (State of Georgia Standards for Involuntary Commitment: GA. Code ANN 37-3-1(9-1). " Inpatient means a person who is mentally ill and A. Who presents a substantial risk of imminent harm to that person or others as manifested by either recent overt acts or recent expressed threats of violence which present a probability of physical injury to that person or other persons ... (B) Who is in need of involuntary inpatient treatment) was initiated and signed on 11/11/2013 at 5:20 p.m., by a Medical Doctor.. The Form 1013 - Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) was reviewed. The 1013 form specified in part, " This is to certify that I have personally examined Patient #10 on 11/11/13 at 1650 which was within the preceding 48 hours of the signing of this certificate. In my opinion this individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND: (x) A. Presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to others persons ... At this time of my evaluation the conditions checked below were present: ...rambling inappropriate speech with multiple threats to father ... this individual (x) Has committed/expressed recent overt acts/threats towards others. .. This certificate authorizes the peace officer or other person to deliver the individual named on this 1013 to the named facility for examination to determine whether admission is necessary. " Handwritten on this form by an RN (staff at transferring facility), " Pt (patient) is being transferred to Floyd Medical Center pending further evaluation & placement at a psych (psychiatric) facility. " Review of nursing notes revealed that patient #10 was drowsy, sleeping with parent at bedside and, ready for transport at 6:50 p.m.


Review of the EMS (Emergency Medical Services) Patient Care Report dated 11/11/2013 indicated Patient #10 ' s Chief complaint was altered mental status secondary to medications. Further review specified, " Narrative: EMS dispatched to an acute care facility for inter-facility transfer to Floyd Medical Center ER ...Request for mental status ...Diagnosis is Psychosis and combative. Pt is being transferred for further mental health eval.(evaluation). Pt being transferred for higher level of care. "


Record review of patient #10 revealed the patient was transferred from a nearby facility to Floyd Medical Center hospital's Emergency Department (ED) on 11/11/2013 at 7:48 p.m. in need of a mental health evaluation. The LPN( licensed practical nurse) performed a triage (Process of sorting people based on their need for immediate medical treatment) on the patient at 7:55 p.m., assigning a level 1 (emergent), and, assessing patient #10 as combative, belligerent, uncooperative, rambling, delusional, hostile, impulsive, and, inappropriate. Review of the physician assessment at Floyd Medical Center on 11/11/2013 at 7:45 p.m., revealed that patient #10 was oriented times three (3) to person, place, time, anxious, combative, and fighting. Geodon 20 mg I.M. was ordered and given by the (LPN) #1 at 7:45 p.m. The patient was also cleared for jail at 7:45 p.m. The discharge diagnosis was documented as schizophrenia and acute agitation, with a differential diagnosis of polysubstance abuse. Review of the Floyd ECC (Emergency Care Center) security form indicated that patient#10 was assigned to Room, and the reason for observation was " 10-13. " Further review indicated the patient was 6 feet 2 inches and weighed 250 pounds. The disposition of patient was listed as " Jail. " The transporting officer was from the local police department and the discharging officer was badge #64. There was no documentation in the medical record to indicate that a mental health evaluation was provided for patient #10 on 11/11/2013. The facility failed to ensure that their policy was followed as evidenced by failing to ensure that on 11/11/2013 patient #10 who was involuntarily committed (1013) received an appropriate mental health screening examination from the appropriate personnel (on-call psychiatrist) which was within the hospital's capability to determine whether or not a psychiatric emergency medical condition existed. According to the triage assessment Patient (#10) presented on 11/11/2013 with manifestations of acute symptoms ( combative, belligerent, uncooperative, rambling, delusional, hostile, impulsive, and, inappropriate) of sufficient severity such that in the absence of immediate medical attention could reasonably be expected to place the health of patient #10 in serious jeopardy as indicated in the facility's policy.


The Psychiatric November 2013 on call schedule for the hospital was reviewed. Review if the Psychiatric schedules revealed that on November 11, 2013 a psychiatrist (capability) was on call to perform a mental health examination on patient #10.


Review of the surveyors notes dated 01/22/2014 revealed that information from the Security Incident report dated 11/22/2013 revealed in part that the incident that occurred at approximately 8:20 p.m., indicated that the alleged altercation revealed that one hospital security guard (interview #3), one (1) contracted security guard, and one contracted off-duty police officer (interview #4) had all completed a report of an incident having occurred. The hospital security guard (interview #3 reported that the patient had suddenly swung at the police officer with his/her right fist, attempting to strike the officer in the head. The officer defended him/her self by striking the patient in the head with his/her right fist, and pushing the patient's upper body until the patient fell onto the end of the bed. Interviewee #2 assisted the police officer (interviewee #4) in wrestling with the patient until the patient was put down on the floor. The police officer Interviewee #4) placed the patient under arrest and applied handcuffs. Shortly after being handcuffed, the patient was medically cleared by the ED physician, and was transported by the police officer to the county sheriff's department. The hospital contracted security guard reported that the patient was making off-the-wall statements. The mental health technician (MHT-employee #2) was in the room to obtain vital signs. The LPN #1 was in the room attempting to talk to the patient. The police officer was in the ED to obtain information for his/her paperwork. The patient was calm at first, but got madder and closer to the nurse while talking to him/her. The nurse had asked the patient to back up and sit on the bed. The patient's attention turned toward the police officer, and he/she took a swing at the officer, then in return, the police officer "took" the patient "to the ground." Then the hospital security guard assisted the police officer to hold the patient down. The nurse returned to give Geodon, but the police officer put the patient in handcuffs. Both security guards waited in the room until a police officer arrived to transport the patient out. The hospital contracted off-duty police officer (interview #4-statement) reported that the patient appeared extremely violent and was uncooperative. He/she had gently touched the patient's elbow, attempting to escort him/her to the bed. The patient immediately pulled away and swung at the officer's head with his/her right fist. The officer ducked, and the patient's hand missed the officer's head. The officer had pushed the patient's upper body and struck the patient above the right eye with his/her right fist, landing the patient on the bed. The officer had placed his/her right hand around the patient's neck and pushed against the patient's upper body to gain control because the patient was attempting to get up. The hospital security guard had assisted to hold the patient down until he/she was placed under arrest for simple battery. The officer further reported that this was done because based on his/her training, knowledge, and expertise. The patient was a threat to the medical staff and all personal in the area.


During an interview with the LPN #1 on 1/23/2014 at 9:10 a.m. in the conference room, he/she recalled the patient, stating that when he/she was trying to get the patient triaged, he/she was standing in the doorway asking "what's going on today?"; The patient started coming toward him/her, yelling and ranting. The nurse had felt threatened enough to knock on the glass window to the office to get the police officer's attention. Both the police officer and a security guard had come out, and there was also another contracted security guard standing nearby. The patient was agitated, and flexing his/her hands open and closed. The police officer stepped in front of the nurse, and the hospital security guard also entered the room. The patient was very agitated, and the nurse left the room for restraints and to request a medication order. After obtaining the restraints, and while getting the medication, the MHT (employee #2) had come to get the restraints from him/her. When the nurse re-entered the room, the patient was in handcuffs, and on one (1) knee on the floor, the stretcher had been removed from the room, and the nurse noticed dried blood on the patient's forehead. The security officer and the police officer had assisted the patient up to a chair, and the nurse had been informed that the patient had swung at the police officer. The patient continued to be agitated and ranting. The nurse had asked the patient if he/she could clean the forehead, the patient had yelled "no", but did allow a Band-Aid to be placed. The nurse thinks he/she gave the patient an injection of Geodon, but wasn't sure, but the restraints were never applied. The nurse had done as much of a triage as the patient would allow, and the physician was phoned to do an assessment. The nurse then went into the office to do charting, and had no further contact with the patient.


Interview with the MHT (employee #2) on 1/22/2014 at 3:15 p.m. in the conference room, after reviewing the hospital's written statements, recalled that patient #10, presented with police escort in handcuffs from the referring facility. Patient #10 was yelling about having anger problems; and the nurse and MHT had requested the patient sit down, and that the patient had refused to sit down. Patient #10 did allow the MHT to take the vital signs standing up. The MHT, nurse, and police officer again asked patient #10 more than once so sit down so as to calm down. Patient #10 stated said his ex-wife took his kids, pointed at the nurse, and started going toward him/her. The MHT stepped between patient #10 and the nurse, nurse knocked on the window, indicating the need for security assistance. The contracted security guard and the contracted police officer went into the room and requested patient # 10 to sit down. The two security persons attempted to deescalate the situation, and patient #10 starting swinging his/her fist at the police officer, making contact with the side of the officer's head. The police officer restrained patient #10 by grabbing his/her arms and pushing him/her onto the bed. The hospital security guard saw what was going on, and went in to assist the police officer to restrain patient #10 by holding him/her down on the bed. The police officer applied hand cuffs and sat patient #10 in a chair to calm him/her down (approximately 5 minutes) and, another police officer had arrived to transport patient #10 to jail.


During an telephone interview with the hospital security guard (interview #3) on 1/22/2014 at 7:00 p.m., he/she recalled that he/she had gone to the ED to pick up a patient for transport to the facility's nearby BH (Behavioral Health) center, and he/she heard someone come in stating they had a patient from another hospital in the ambulance who was becoming combative and violent. There were officers there and the emergency medical service (EMS) persons brought the patient to the BH area. The patient was in the office, could hear yelling, and thought there might be a problem. The patient would not transfer from the stretcher to the bed, was uncooperative and cursing. Someone had knocked on the window, and he/she believed they needed help. The police officer was already in the room when he/she went over there and the nurse and MHT were trying to get the patient to sit so they could check the vital signs. The police officer and a security officer were already in the room, and the police officer kept trying to get the patient to sit down. The patient was cursing and being uncooperative, then suddenly swung at the police officer's head. The police officer struck the patient in the head and had gone around the other security guard to help. The patient was on the side of the bed, and the patient and the police officer wrestled around, and the patient fell on the far end corner of the bed. The hospital security guard assisted the police officer to hold the patient down, and the police officer applied hand cuffs.


During an interview with the police officer (interview #4) on 1/23/2014 at 10:02 a.m. in the conference room, he/she recalled the patient (#10), but stated that this is an open case, and he/she had been advised that he/she could not discuss the case.

The surveyor was informed that the contracted security guard had been terminated, and was not available to be interviewed.

Interview with the contracted security's account manager (interview #5) on 1/22/2014 at 3:40 p.m. revealed that actions taken by the police officer were more in line with what he/she would have been trained to do as a police officer. Police officers "use their judgment as police officers", and that he/she "could not interfere with them doing their job- they are in their uniform and representing their agency."

A telephone interview was conducted with the ED physician (credential #2) on 2/10/2014 at 4:00 p.m. The ED physician recalled patient #10, stating that the transferring facility had phoned regarding the patient transfer, and patient #10, did not receive a mental health evaluation because he/she had been told by security that the patient's violence at that point was beyond what the facility could safely control for staff.

Interview with the ED Medical Director (interview #10) on 2/10/2014 at 4:30 p.m. revealed that an associated critical access hospital sent behavioral health (BH) patients to this facility for evaluations because the patients were difficult to manage and the facility lacked security there. He further stated in general, if a BH patient arrived swinging/punching, the ER physician would do a MSE to determine medical clearance. If the patient already had laboratory studies performed, and was uncontrollable, they may go to jail, depending on the severity of the signs/symptoms. The police officer was there to protect the staff.

The facility failed to ensure that their policy , "Care of the Patient with Assaultive Behavior " was followed as evidenced by failing to call "Code Grey" on 11/11/2013 for patient #10. There was no documentation in the medical record to indicate that "Code Gray " was called. The facility also failed to follow their policy related to Care of the Mental Health Patient as evidenced failing to ensure the Floyd Mental Health Screener was called to work collaboratively with patient/family, clinical staff, ED physician and the on call psychiatrist to appropriately screen Patient #10 on 11/11/2013 and determine appropriate treatment. On 11/11/2013 Patient #10 required inpatient psychiatric treatment for definitive care.

2407

Based on review of medical records, policies and procedures, on call schedules, behavioral health bed census report and interviews the facility failed to ensure that stabilizing treatment was provided as required that was within the capability and capacity of the hospital for one (1) patient (#10) for one of twenty sampled patients. Cross refer to Tag 2406 for additional information regarding patient #10.

Findings include:

Review of facility policy AD-03-039, Respecting EMTALA (COBRA) Compliance, developed 12/90, last review date 2/02, last revision date 3/03, revealed in part, " Required Action if Emergency Medical Condition is Found to Exist:Once it is determined that an emergency Medical condition exists, the staff at FMC shall provide either: a. Such other and further medical examination and treatment, within its capabilities, as may be required to stabilize the medical condition... or b) For transfer of the patient to another facility."

The Psychiatric November 2013 on call schedule for the hospital was reviewed. Review if the Psychiatric schedules revealed that on November 11, 2013 a psychiatrist (capability) was on call to perform a mental health examination for patient #10.

Review of the facility's bed census report for November 11, 2013 was Adult Psych/Chemical Dependency Unit revealed the census was 23. Floyd Medical Center has a Behavioral Health unit with a capacity of 53 beds.


An interview was conducted with the ED medical Director on 2/10/2014 at 4:00 p.m. The ED director stated that physicians can review laboratory results, nursing notes, and past medical history on the computer, and the facility usually received a copy of the physician's notes with the transfer sheet. If patients were deemed to be unsafe, staff would try to sedate them, and continue treatment, but if staff could not calm the patient, and they threatened staff or became violent, the police officer became involved. The facility failed to ensure that their policy regarding stabilizing treatment was followed as evidenced by failing to ensure that further examination and psychiatric treatment was provided as required for patient #10 with an identified psychiatric emergency (1013) that was within the capability and capacity of the hospital on 11/11/2013.