HospitalInspections.org

Based on interview, and record review, the facility failed to comply with CFR 489.24 by failing to ensure:

1. One patient who arrived at the facility by ambulance after seizing for 30 minutes (Patient 101) was provided a MSE (medical screening examination) when the patient was diverted to another facility immediately after arriving. This failed practice resulted failure to provide stabilizing treatment and obtain an accepting physician prior to transfer, and the potential for harm or death during transfer (A2406);

2. Patients coming voluntarily to the Psychiatric Emergency Department (PED) requesting treatment received a MSE appropriate to the individuals' presenting signs and symptoms to determine if an emergency medical condition existed. This failure resulted in 11 patients (Patients 202, 203, 204, 205, 207, 400, 404, 405, 406, 407 and 410) leaving the PED without a MSE due to; a) suggestions by the triage nurse of long wait times; and, b) being coerced to agree to admission to the locked psychiatric unit in order to receive a MSE. This failed practice resulted in the potential for exacerbation of their medical and/or psychiatric condition, harm, or death (A2406);

3. One nurse who was assigned to perform Labor & Delivery (L&D) triage and perform the MSE met the qualifications outlined in the facility's standardized procedure for one of three employee files reviewed (A2406); and,

4. The Psychiatric Emergency Department (PED) central log was maintained to include whether the patient refused treatment, or was refused treatment by the hospital (A2405).

These failed practices resulted in inappropriate transfer from the facility, patients leaving without receiving a MSE due to suggestions and coercion by the facility, MSEs being performed by unqualified personnel, inability to determine whether patients were leaving due to refusing treatment or being refused treatment, and the potential for worsening of their conditions, harm and death.

Based on interview and record review, the facility failed to ensure the Psychiatric Emergency Department (PED) central log was maintained to include whether the patient refused treatment, or was refused treatment by the hospital. This failure had the potential to result in the inability to determine if patients were treated, refused treatment, or were denied treatment.

Findings:

On July 1, 2014, the PED central log covering a six month period was reviewed.

Multiple areas on the logs were incomplete and did not include the date and the time the patient arrived and left the PED, and whether the patient refused or was denied treatment.

An interview was conducted with the Assistant Chief Nursing Officer (ACNO), on July 1, 2014, at 11:25 a.m. The ACNO stated the Medical Unit Clerk (MUC) entered the information for the PED central log.

The ACNO reviewed the PED central log. The ACNO stated if the patient was not seen by a physician, the facility did not document the date, time, and why the patient was not seen (if the patient refused or was denied treatment).

An interview with MUC 1 was conducted on July 2, 2014, at 11:50 a.m. The MUC stated the areas on the PED central log that indicated the date, time, and whether the patient had refused or was refused treatment were not completed because, "They (the patients') do not enter the locked area."

The facility policy and procedure titled "Federal Emergency Medical Treatment and Active Labor Act (EMTALA)," dated August 3, 2011, indicated the central log would record the name of each person who presented for emergency services and whether the person refused treatment or was refused treatment by the hospital.

Based on interview and record review the facility failed to ensure:

1. One patient who arrived at the facility by ambulance after seizing for 30 minutes (Patient 101) was provided a MSE (medical screening examination) to determine whether an emergency medical condition existed when the patient was diverted to another facility immediately after arriving. This failed practice resulted failure to provide stabilizing treatment and obtain an accepting physician prior to transfer, and the potential for harm or death during transfer;

2. Patients coming voluntarily to the Psychiatric Emergency Department (PED) requesting treatment received a MSE appropriate to the individuals' presenting signs and symptoms to determine if an emergency medical condition existed. This failure resulted in 11 patients (Patients 202, 203, 204, 205, 207, 400, 404, 405, 406, 407 and 410) leaving the PED without a MSE due to; a) suggestions by the triage nurse of long wait times; and b)being coerced to agree to admission to the locked psychiatric unit in order to receive a MSE. This failed practice resulted in the potential for exacerbation of their medical and/or psychiatric condition, harm, or death; and,

3. One nurse assigned to do Labor & Delivery (L&D) triage and perform the MSE met the qualifications outlined in the facility's standardized procedure for one of three employee files reviewed. This failed practice resulted in Registered Nurse (RN) 7 being assigned to perform the MSE on obstetrical patients without meeting the qualifications, and the potential for harm or death to the mothers and unborn babies.

The Chief Nursing Officer, Assistant Chief Nursing Officer, and Associate Hospital Administrator were notified that Immediate Jeopardy was identified on July 2, 2014, at 11:05 a.m. The Immediate Jeopardy was identified due to the facility's failure to provide medical screening examinations to patients presenting voluntarily to the Psychiatric Emergency Department at the Arlington Campus, resulting in patients leaving without examination and identification of treatment needs, and the potential for harm or death to the patients.

An acceptable plan of correction was received and, following verification of implementation of the plan, the Chief Nursing Officer, Assistant Chief Nursing Officer, and Associate Hospital Administrator were notified the Immediate Jeopardy was abated on July 2, 2014, at 3:45 p.m.

Findings:

1. During an interview with the Emergency Department Manager (EDM) on June 25, 2014, at 10:30 a.m., the EDM stated on June 2, 2014, the MICN (Mobile Intensive Care Nurse) received a call on the EMS (Emergency Medical Systems) radio from an ambulance crew who had been called to a school and were providing care to a seven year old female who had been seizing for 30 minutes (Patient 101). According to the EDM, the paramedic stated the child's mother wanted the child to be taken to a hospital 20 to 30 minutes away (Facility 2), but the MICN spoke to the mother and, "convinced," her to let the ambulance bring the child to the Moreno Valley Campus (only five minutes away) to prevent a delay in treatment for her seizures. The EDM stated the MICN walked out of the radio room and told the ED physician the child was coming and was five minutes away. The EDM stated the ED physician told the MICN to redirect the ambulance to Facility 2. The EDM stated as the MICN was attempting to contact the ambulance crew by radio, they pulled up to the Moreno Valley Campus ED ambulance entrance, and the MICN went out and told them to take the child to Facility 2. The EDM stated the ambulance was on the Moreno Valley Campus property, and the child was being taken off of the ambulance, when they were directed to leave and transport the child to Facility 2.

The, "Base Station Hospital Mobile Intensive Care Record," used by the MICN to document calls received by ambulance crews, was reviewed on June 25, 2014. The record indicated on June 2, 2014, at 9:39 a.m., the MICN received a call from an ambulance crew who was caring for a seven year old female (Patient 101). The record indicated the patient had been seizing for 30 minutes. According to the record, the mother wanted the child to be taken to a hospital 20 to 30 minutes away (Facility 2), and the MICN, "Spoke with mother and strongly encouraged transport to closest hospital (the Moreno Valley Campus). Mother agreed for transport to (the Moreno Valley Campus)." The record further indicated, "Per (ED physician) (ambulance) called and diverted to (Facility 2).

The ambulance, "Patient Care Report," was reviewed on June 25, 2014. The narrative notes indicated Patient 101, a seven year old female, had a GCS (Glascow Coma Scale [a scale used to determine the conscious state of a person]) of three (the lowest possible score), indicating the child was unresponsive. According to the notes, Patient 101 was having a seizure, presenting as eyes tightly closed and fixed to the right, loss of bladder control, and drooling. The notes indicated the seizure had been ongoing for 30 minutes. The notes indicated the paramedic contacted the Moreno Valley Campus for assistance in determining a destination hospital, and the MICN wanted the child to be brought there due to her seizure activity for the past 30 minutes and a five minute ETA (estimated time of arrival). The notes further indicated as the ambulance crew walked into the ED at the Moreno Valley Campus with Patient 101, the MICN apologized but said the ED physician wanted the child to be taken to (Facility 2) if her respiratory rate and oxygenation were, "stable." According to the notes, the MICN checked the patient's vital signs and, "approves transfer to (Facility 2) with a 30 minute ETA."

During an interview with the MICN on July 2, 2014, at 9:15 a.m., the MICN stated she took the radio call on Patient 10. The MICN stated she was concerned regarding the ETA to (Facility 2), so she spoke to the child's mother who agreed for her child to come to the Moreno Valley Campus for stabilization. The MICN stated she went to notify the ED physician about the child who was on her way by ambulance with a five minute ETA, and the physician told her to divert the ambulance to (Facility 2). The MICN stated she reminded the physician the ambulance had an ETA of five minutes, and he told her to, "divert them anyway." The MICN stated she met the ambulance at the ED entrance where they were taking Patient 101 out of the ambulance, and she told them the ED physician wanted them to continue on to (Facility 2). The MICN stated the ambulance was diverted without the patient being seen by a physician.

Patient 101 was transferred to Facility 2 immediately after arriving to the Moreno Valley Campus, without receiving a MSE.



22384

2. During an interview with the PED Nurse Manager (NM) (at the Arlington Campus) on July 1, 2014, at 2:20 p.m. The NM stated in triage, "We have to tell patients it will take a while to be seen. Part of the assessment, if the patient is voluntary, is saying it will be a long wait."

During an interview with the Associate Hospital Administrator (AHA) at the Arlington Campus on July 1, 2014, at 2:25 p.m., the AHA stated when voluntary patients arrived in the triage area requesting care and services, they were, "a low priority," so they may have to wait eight to 12 hours to be seen by a physician (for a MSE). The AHA stated the voluntary patients had to agree to be admitted to the locked unit if they wanted to receive a MSE, as the Arlington Campus was, "a locked unit," and they could not have the physicians come into the unlocked area to see the voluntary patients to provide a MSE. The AHA stated, "It is their choice if they want to leave."

During an interview with Registered Nurse (RN) 1 on July 1, 2014, at 3 p.m., RN 1 stated when patients came to the PED triage area voluntarily requesting treatment, she told them they had to be admitted into the locked unit to be seen by a physician. The RN stated the patients would say they wanted to be seen, but they did not want to be, "locked up," so they would leave. The RN stated, "I also inform the patient of the wait time."

During an interview with RN 2 on July 2, 2014, at 9:30 a.m., RN 2 stated during the triage process with voluntary patients, she informed the patients this (the Arlington Campus) was a locked facility. The RN stated she tried to have the patient agree to and sign a consent for admission to the locked unit in order to be seen by a physician. The RN stated if the patient refused admission to the locked unit to be seen by a physician, she may call the social worker who then would evaluate the patient and give them referrals, which may include clinic referrals. RN 2 further stated she informed the patients at triage the wait time could be six to seven hours.

a. A review of Patient 202's record was conducted. The triage note indicated Patient 202, a 28 year old female, presented voluntarily to the PED on March 14, 2014, at 12:02 p.m., requesting a referral for counseling due to depression. No vital signs were documented for the patient. The note indicated the patient was given information regarding counseling for depression at triage.

Patient 202 was categorized as a "Walk Away" patient. There was no evidence to show a MSE was offered or provided.

During an interview with the Assistant Chief Nursing Officer (ACNO) on July 1, 2014, at 1:45 p.m. The ACNO stated a "Walk Away" patient was a patient who walked into the PED and then walked out of the PED.

b. A review of Patient 203's record was conducted. The triage note indicated Patient 203, a 19 year old male, presented voluntarily to the PED on April 2, 2014, at 1:13 p.m., after he, "had a breakdown because of a relationship issue." No vital signs were documented for the patient.

Further documentation indicated the patient decided he did not want to wait and left at 1:30 p.m. The patient was categorized as a "Walk Away" patient. There was no evidence to show a MSE was offered or provided.

c. A review of Patient 204's record was conducted. The triage note indicated Patient 204, a 28 year old female, presented voluntarily to the PED on April 4, 2014, at 11:47 a.m., with a chief complaint of, "medications". There was no further information regarding the, "medication."

The documentation indicated the triage nurse informed the patient the wait could be 6-8 hours, and she did not want to wait, so she left with her mother at 12:45 p.m. (an hour after arriving).

The patient was categorized as a "Walk Away." There was no evidence to show a MSE was offered or provided.

d. A review of Patient 205's record was conducted. The triage note indicated Patient 205, a 32 year old female, presented voluntarily to the PED on May 19, 2014, at 2:30 p.m., requesting to see the physician for a medication refill. The note indicated the patient was not eating or sleeping, and was, "Saying strange things." According to the record, the patient had been out of her medications for three months.

The record indicated medications the patient had been taking included Prozac 20 milligrams one capsule orally daily (among the diagnoses Prozac is used for are, depression, obsessive-compulsive disorder [bothersome thoughts that won't go away and the need to perform certain actions over and over], borderline personality disorder and panic attacks). Patient 205 also had been taking Trazodone 50 milligrams orally every evening as needed (used to treat major depressive disorder)."

The triage nurse documented, "Informed pt. 8-10 hr. wait for services...Pt. does not want to stay. Will go to clinic in Hemet."

Patient 205 was categorized as a "Walk Away" patient. There was no evidence a MSE was offered or provided to Patient 205.

e. A review of Patient 207's record was conducted. The triage note indicated Patient 207, a 51 year old male, presented voluntarily to the PED on March 19, 2014, at 2:30 p.m., requesting medications for paranoid schizophrenia and feeling like people were, "after," her.

The triage nurse documented, "Pt. is requesting med stabilization and psych (psychological) evaluation, paranoid, believes people are after him; off meds for few months, ambulatory (walking) with steady gait...informed him of the psych evaluation and possible wait time of 6-8 hours...verbalized understanding, he walked away with friends."

Patient 207 was categorized as a "Walk Away" patient. There was no evidence to show a MSE was provided.



29542

f. The record for Patient 400 was reviewed. Patient 400, an 11 year old female, presented voluntarily to the PED, on April 23, 2014, with the chief complaint, "I was having suicidal thoughts (thoughts of killing oneself). I wanted to die...I was just wishing to die."

The triage note indicated the nurse explained the process involving wait times of eight to 10 hours, so the foster mom decided to leave and take the patient to her primary caregiver, then follow up with her therapist the next day.

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided.

g. The record for Patient 404 was reviewed. Patient 404, a 29 year old female, presented voluntarily to the PED, on May 7, 2014, requesting a medication refill.

The triage note indicated the patient's mom stated her daughter had been off her meds for three days and she did not want her to escalate. According to the note, the triage nurse told the patient about the wait and gave her a list of clinics, then she chose to leave.

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided for Patient 404.

h. The record for Patient 405 was reviewed. Patient 405, a 24 year old female, presented voluntarily to the PED, on January 3, 2014, requesting a medication refill.

The triage note indicated the patient refused admission (to the locked unit) as she had to get home to her small child, then was advised by the triage nurse to, "come back anytime as needed."

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided for Patient 405.

i. The record for Patient 406 was reviewed. Patient 406, a 41 year old female, presented voluntarily to the PED, on January 3, 2014, stating she needed counseling, "only," and did not want admission (to the locked unit).

The triage note indicated the patient refused admission and was advised by the triage nurse to, "come back any time as needed."

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided for Patient 406.

j. The record for Patient 407 was reviewed. Patient 407, a 14 year old female, presented voluntarily to the PED, on May 7, 2014, complaining of hearing voices and seeing things ("everything wrapped up"), and thoughts of hurting herself.

The triage note indicated the patient's mother decided to take her to another facility, and left at 11:50 a.m.

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided for Patient 407.

k. The record for Patient 410 was reviewed. Patient 410, a 21 year old male, presented to the PED, on June 11, 2014, stating he was feeling suicidal.

The triage note indicated the patient told the nurse he wanted to go to rehab for substance abuse, and she provided clinic information, then he left.

The patient was categorized as a "Walk Away." There was no evidence a medical screening exam was offered or provided for Patient 410.

Due to the information provided by the triage nurses regarding the long wait times and having to be placed in a locked facility in order to be seen by a physician to receive a MSE, the eleven voluntary patients reviewed did not receive a MSE and chose to "Walk Away."

The facility policy titled, "Federal Emergency Medical Treatment and Active Labor Act," was reviewed on July 1, 2014. The policy indicated the following:

a. It applied to any individual who came to the Moreno Valley Campus or the Arlington Campus;

b. The dedicated emergency departments in the facility included the Moreno Valley Campus emergency department, Labor and Delivery, and the Arlington Campus emergency department;

c. A medical screening examination would be offered to any individual who came to the emergency department to determine whether an emergency medical condition existed, and the individual must receive the same examination the hospital would perform on any individual with similar signs and symptoms;

d. Triage was not equivalent to a medical screening examination, and was merely to determine the order in which individuals would be seen, not the presence or absence of an emergency medical condition; and,

e. An individual with an unstabilized emergency medical condition could be transferred only if: 1) the hospital provided treatment within it's capacity to minimize the risks to the individual's health; 2) the receiving facility had available space and qualified personnel to treat the individual; 3) the receiving facility and a receiving physician agreed to accept the individual and to provide appropriate medical treatment; 4) the hospital sent to the receiving facility all copies of medical records available at the time of the transfer; and, 5) the transfer was effected using proper personnel and equipment, as well as necessary and medically appropriate life-support measures.



28294

3. On July 1, 2014, at 8:20 a.m., an interview was conducted with Registered Nurse (RN) 6 during a tour of the Labor & Delivery unit. RN 6 stated not all of the L&D nurses were assigned to do the triage for Obstetrical (OB) patients, and in order for the nurse to be assigned to the triage of L&D patients she would have to complete MSE training. In addition, RN 6 stated the triage nurse did the MSE for patient's presenting to L&D who have a private practice physician.

On July 2, 2014, the employee file for Registered Nurse 7 was reviewed. RN 7 was hired on April 10, 2008, and her last Advanced Fetal Monitoring class was taken on October 27, 2011 (2 years and 8 months ago). There was no indication RN 7 had completed MSE and EMTALA (Emergency Medical Treatment and Active Labor Act) training.

The L&D triage log and staff assignment sheets indicated RN 7 was assigned to do L&D triage, on the 7 p.m. shift, on April 11, 17, 21, 22, and 27; May 5, 15, and 23; June 3 and 30; and July 1, 2014 (11 shifts in 3 months).

During an interview with the Manager of L&D (MLD), on July 2, 2014, at 12 p.m., she reviewed the employee file for RN 7 and was unable to find documentation of MSE/EMTALA training being completed by RN 7. The MLD stated nurses assigned to L&D triage should meet the qualifications as outlined in the facility's standardized procedure "Obstetrical Medical Screening Exam." In addition, the MLD stated an Advanced Fetal Monitor course must be completed within two years from the hire date, and then a refresher/review/update class or module must be completed every two years after the initial Advanced Fetal Monitor course. The MLD stated RN 7 had not completed the requirements for a refresher/review/update class or module on fetal monitoring.

The facility standardized procedure titled "Obstetrical Medical Screening Exam" dated April 2013, revealed "... The Registered Nurse may be considered a Qualified Medical Personnel and may perform OB Medical Screening Exam once the following requirements are met: ... Training: ... Complete the MSE in service self study with a satisfactory passing score (80% or more correct). AWHONN (Association of Women's Health, Obstetrical, and Neonatal Nurses) Advanced Fetal Monitoring, Current on Fetal Monitoring Class requirements, ... Initial evaluation: Complete triage and outpatient care of two separate patients, verified competent by the attending physician. ..."