HospitalInspections.org

Based on records reviewed and interviews, the Condition Participation for Governing Body Condition was not met as evidenced by evidnce that hospital officials contacted law enforcement agencies and Emergency Medical Services (EMS) providers advising them not to transport mental health patients to their emergency department, .

Findings included:

1. During an interview on May 14, 2018 at approximately 3:19 PM, the Chief Nursing Officer (CNO) reported that she met with the Police Chiefs for both cities of Lewiston and Auburn, regarding which hospitals the police transport individuals in custody.

The CNO also stated that she met with the local ambulance service to discuss behavioral health patients transported to CMMC (Central Maine Medical Center). The CNO reported several emergency department (ED) physicians had expressed concern regarding psychiatric patients coming to a facility with no psychiatric services.

During interviews on May 17-19, 2018, with several Emergency Medical Services providers, it was reported that on arrival at CMMC ED with patients seeking mental health care, the Paramedics reported that the ED staff would question the EMT's decision to transport the patient to CMMC. EMT #1, who manages the local ambulance service, reported that the CNO contacted him regarding mental health patients being transported to CMMC. EMT #1 stated that he advised the CNO that the patient has the right to choose which hospital they are transported to. EMT #2 reported that once on arrival to the CMMC ED, a staff nurse asked, "Why are you taking a mental health patient here?" And when EMS #2 was working for a different ambulance he/she was told to call in by phone and was informed that mental health patients should be transported to a different hospital. EMS #3 reported that a patient had requested transport to CMMC and when the ambulance called in they were advised to divert to the other hospital, since "we don't offer those services." It was reported that the nurse called the Ambulance Officer later and reported that she "messed up."

The Director of Security sent an email to the Androscoggin County Sheriff's Office instructing the Sheriff's Office; "...if someone is in custody and is suicidal or in need of mental health issues that person is to be transported to [other hospital]. CMMC is a trauma center and cannot provide the proper care for mental health."

The Director of Security confirmed on May 16, 2018 at approximately 11:00 AM that he did send an email to the Sheriff's Office.

The CNO confirmed on May 18, 2018 at approximately 9:05 AM that she had discussed transporting mental health patients with the local ambulance service.


2. Standard: §482.12(a)(5) Medical Staff Accountability also known as A0049 - Based on record reviews and interview, it was determined that the Governing Body failed to assure the quality of patient care determination by Emergency Department (ED) Providers, were based on complete and accurate medical record information provided by contracted providers completing emergency crisis evaluations for 11 of 27 sampled patient records (Patient #2, #5, #6 - 2 records, #7 - 2 records, #9, #12 - 3 records, and #14). See A0049 for details.

3. Standard: §482.12(e) Contracted Services also known as A0083 - Based on record review and interviews, the Governing Body failed to assure through the Quality Assessment and Performance Improvement that contracted services were monitored to identify performance problems and to assure improvement activities are implemented for 1 of 1 Crisis Service contracts reviewed. See A0083 for details.

The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.

Based on record reviews and interview, it was determined that the Governing Body failed to assure the quality of patient care determination by Emergency Department (ED) Providers, were based on complete and accurate medical record information provided by contracted providers completing emergency crisis evaluations for 11 of 27 sampled patient records (Patient #2, #5, #6 - 2 records, #7 - 2 records, #9, #12 - 3 records, and #14).

This finding includes:

On May 15, 2018 a request was made for "Complete ED Records" for 27 records chosen from the Emergency Department Log. On receipt of the records, 11 of 27 Emergency Department records reviewed indicated that the records failed to contain a copy of the crisis assessment/evaluation report.

- A review of the record for Patient #2 found an ED Physician note, dated 9/20/17 at 9:05 PM, which stated, in part, "Patient was evaluated by crisis who felt the patient was stable for outpatient management. [He/She] has no SI, HI or confusion or psychosis. [He/She] is able to contract for safety." A further review of the record found that the record failed to contain documentation of the crisis assessment.

- A review of the record for Patient #5 found an ED Physician note, dated 10/22/17 at 12:21 PM, which stated, in part, "Seen by Tri-County intervention. Patient has been accepted to Deer Run for respite care ...". A further review of the record found that the record failed to contain documentation of the crisis assessment.

- A review of the record for Patient #6 found a ED Physician note, dated 4/06/18 at 12:52 PM, which stated, in part, "The patient became agitated when [community provider] Act Team worker suggested that [he/she] would be OK to go home." The record also contained the following nurse's documentation, dated 4/6/18 at 4:10 PM, "After pt's ACT team member visited and recommended pt be discharged, pt became upset and said [he/she] needs to stay in the hospital ... [ED Physician] spoke to the patient and decided the patient was safe to be discharged with the recommendation from [community provider] Mental Health." A further review of the record found that the record failed to contain documentation of the referenced [community provider] Mental Health assessment and recommendation that patient be discharged.

- A review of an additional record for Patient #6 found an ED Provider note, dated 4/26/18 at 7:26 AM, which stated, in part, "Medical Decision Making ... [Patient] was signed out to me pending psychiatric placement following evaluation by [crisis provider]." The record also contained Nursing documentation dated 4/26/18 at 3:26 AM stating; "0145-[Crisis Provider Agency #2] Representative/councilor at bedside to assess pt." And, "0217- [Crisis Provider Agency #2] Rep. informed me that she will be looking for inpatient, psychiatric care at [other hospital]; no beds available tonight; provider aware." A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient by [Crisis Provider Agency #2].

- A review of the record for Patient #7 found an ED Provider note, dated 4/10/18 at 4:02 AM, which stated, in part, "[patient] who was signed out to me awaiting evaluation by [Crisis Provider Agency #1] for suicidal ideation ... [He/she] was violent by [Crisis Provider Agency #1] who is seeking an inpatient bed." A further review of the record found nursing documentation, dated 4/11/18 at 1943 (7:43 PM) which stated [Crisis Provider Agency #1] Rep informed me that Pt was accepted to [psychiatric hospital." Additionally; Suicide Precautions Monitoring documentation dated 4/10/18 at 9:31 AM, "Observed Pt Activity: Sitting up in chair, Other: talking with [Crisis Provider Agency #2]". A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient by Crisis Provider Agency #1 or #2.

- A review of an additional record for Patient #7 found an ED Provider note, dated 5/8/18 at 2:45 AM, which stated, in part, "[Patient #7] was seen by [ED Physician] and medically cleared signed out to me awaiting crisis evaluation. This was completed [Patient #7] felt to be appropriate for inpatient care in the process of placement as started." Patient Care Note documented on 5/8/18 at 7:21 AM, "Patient Care Followup: 0721 (7:21 AM) [Crisis Provider Agency #2] arrived to talk with patient ...". A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient by crisis provider agency #2.

- A review of the record for Patient #9 found an ED Provider note, dated 4/2/18 at 10:54 PM, which stated, in part, "I have asked crisis to see [him/her]. I do not think [he/she] requires acute inpatient hospitalization. Signed out to my colleague pending crisis eval." The ED Provider note, 4/2/18 at 11:45 PM, stated, in part, "Medical Decision Making: [Patient #9] with suicidal ideation without specific plan signed out to me awaiting crisis evaluation." The record also contained Suicide Precautions Monitoring documentation dated 4/3/18 at 3:57 AM, stating, in part, "Observed Pt activity: Lying in bed. Other: talking with [Crisis Provider Agency #1]." A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient by [crisis provider agency #1].

- A review of the record for Patient #12 found an ED Provider note, dated 4/27/18 at 1:24 AM, which stated, in part, "Medical Decision Making ... I have also contacted [Crisis Provider Agency #2] for psychiatric evaluation. Crisis evaluation and placement is pending at the end of my shift." A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient by [crisis provider agency #2].

- A review of a second record for Patient #12 found an ED Provider note, dated 4/28/18 at 10:54 PM, which stated, in part, "Medical Decision Making ... [Patient #12] here with suicidal ideation with plan although limited means. Patient is currently awaiting psychiatric evaluation." A further review of the record found that the record failed to contain any documentation of the referenced psychiatric evaluation of the patient being performed.

- A review of a third record for Patient #12 found an ED Provider note, dated 5/13/18 at 2:55 AM, which stated, in part, "Medical Decision Making ... I spoke with crisis for evaluation for patient's spell polysubstance abuse as well as depression and SI. They evaluated the patient. They recommended inpatient placement ...". The record also contained a patient care note dated 5/13/18 stating, "1530 (3:30 PM) - [Crisis Provider Agency #2] rep speaking with patient at this time. AS RN". A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient performed by [crisis provider agency #2].

- A review of the record for Patient #14 found an ED Provider note, dated 1/12/18 at 10:16 PM, which stated, in part, "Medical Decision Making ... Pt met with [Crisis Provider Agency #1] who will seek inpatient treatment". The record also contained Patient Care Note dated 1/13/18 at 9:11 PM stating, in part, "Patient Care Followup: [Crisis Provider Agency #1] Called at this time. Per [Crisis Provider Agency #1] patient will be assessed in the morning. No beds for placement at this time ..." A further review of the record found that the record failed to contain documentation of the referenced assessment/evaluation of the patient performed by with [Crisis Provider Agency #1].

During an interview with RN #3 on May 15, 2018 at approximately 12:30 PM, it was confirmed that the medical records provided did not all contain documentation of the crisis evaluation, when the record indicated that an evaluation had been performed. RN #3 reported that Medical Record staff were not able to locate the crisis evaluations for several of the requested records, where a crisis evaluation had been documented. RN #3 stated; "We need to monitor getting these reports from crisis". Additionally, RN #3 stated, "[MD #1] noticed the same thing, difficulty getting information from [Crisis Provider Agency #1]. Part of the contract with [Crisis Provider Agency #2] is to assure information is provided."

Based on record review and interviews, the Governing Body failed to assure through the Quality Assessment and Performance Improvement that contracted services were monitored to identify performance problems and to assure improvement activities are implemented for 1 of 1 Crisis Service contracts reviewed.

The finding includes:

A review of the "Crisis Services Agreement" contract that was in effect from August 24, 2016 to May 1, 2018, indicated "Crisis worker will provide the written assessment to the Clinical supervisor at CMMC, or designee. If circumstances prevent crisis worker from completing the written assessment at the time of the interview, crisis worker will fax the assessment to the ... at CMMC." A review of 17 patient records where the record documented a crisis evaluation was done, only 6 records contained a copy of the crisis assessment. The "Clinical Contract Evaluation Form" failed to monitor compliance with providing documentation as required in the contract.

This finding was confirmed with the Regulatory Compliance Coordinator and the Covering Compliance Officer on May 21, 2018 at approximately 11:00 AM, who agreed that the hospital was not monitoring the receipt of documents from the crisis provider at that time.