HospitalInspections.org

1. Based on review of Medical Records (MR), facility policies and procedure and interviews with staff, it was determined the facility failed to ensure that an appropriate medical screening examination was provided with in the capability of the hospital's emergency department by failing to place Patient #8 on a court ordered or mandated involuntary psychiatric hold as the patient presented to the facility with suicidal ideations, an identified psychiatric emergency medical condition: The facility failed to:

1. Place Patient #8 who presented to the emergency department with suicidal ideation on involuntary psychiatric hold; Patient did not have mental competency to make own decision to leave the facility against medical advice given his presenting sign and symptoms of suicidal ideations.

2. Encourage a patient presenting with Suicidal Ideation (SI) with attempt not to leave the Emergency Department (ED) prior to arranging for a transfer to complete the Medical Screening Exam (MSE).

3. Document the provision of Suicidal Precautions for a patient who presented with SI with an attempt.

4. Reassess presence of SI prior to a patient's discharge from the facility.

This deficient practice affected one of one MR's reviewed with SI who left AMA, including Patient Identifier (PI) # 8 and had the potential to affect all patients served by the facility Emergency Department (ED) with SI.

Refer to findings in Tag A- 2406.


2. Based on medical record reviews, Emergency Department Logs, Emergency Department Video footage, ED/Hospital Census, letter from the complainant, Policy and Procedure and staff interviews it was determined that the facility failed to offer further medical screening examination and treatment, and failed to explain to the individual the risks and benefits of leaving the without further examination and treatment.

This affected one of 21 sampled medical records including Patient #15.

Refer to findings in Tag A- 2407.

Based on review of Medical Records (MR), facility policies and procedure and interviews with staff, it was determined the facility failed to ensure that an appropriate medical screening examination was provided with in the capability of the hospital's emergency department by failing to place Patient #8 on a court ordered or mandated involuntary psychiatric hold as the patient presented to the facility with suicidal ideations, an identified psychiatric emergency medical condition: The facility failed to:

1. Place Patient #8 who presented to the emergency department with suicidal ideation on involuntary psychiatric hold; Patient did not have mental competency to make own decision to leave the facility against medical advice given his presenting sign and symptoms of suicidal ideations.

2. Encourage a patient presenting with Suicidal Ideation (SI) with attempt not to leave the Emergency Department (ED) prior to arranging for a transfer to complete the Medical Screening Exam (MSE).

3. Document the provision of Suicidal Precautions for a patient who presented with SI with an attempt.

4. Reassess presence of SI prior to a patient's discharge from the facility.

This deficient practice affected one of one MR's reviewed with SI who left AMA, including Patient Identifier (PI) # 8 and had the potential to affect all patients served by the facility Emergency Department (ED) with SI.

Findings include:

Facility Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Policy
Review/Revision Date: 2/5/21

...Introduction: The purpose of this policy is to define the relevant terms and provide an overview of the EMTALA...

...Definitions:

...MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition (EMC) exits...The MSE is an ongoing process, and the MR must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred.

...II. MSE

...B. Medical Screening...The MSE includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an EMC...Note that an MSE is not an isolated event, but it is an on-going process. Thus, the MR must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, discharged, admitted or appropriately transferred.

Facility Policy: Care of Appropriate Referral When Primary Diagnosis is Psychiatric or Substance Abuse
Reviewed Date: 12/21

Purpose or Policy Statement: Patients with primary psychiatric...diagnoses are to be transferred to a more appropriate facility...Patients who are known to be suffering...mental illness shall be transferred to an appropriate treatment facility whenever possible. Proper safety precautions can be taken to safeguard the patient...The admitting physician shall assess the patient for suicidal...risks and order appropriate precautions...A transfer to a more appropriate facility shall be expedited as soon as is medically possible. However, while the patient is in the hospital, he/she shall be under observation per the suicide policy scoring level for observation/surveillance by nursing personnel or trained responsible caregiver.

Facility Policy: Suicide Risk Assessment and Interventions
Revision Date: 7/6/22

Policy: All...adult patients who present for care and services will be screened for SI and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS)...Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. This policy is applicable to non-behavioral health settings including the ED...

...Definitions:

...SI; Thoughts of harming or killing oneself...

....Suicide Attempt: A self-injurious act committed with at least some intent to die, as a result of the act. There does not need to be any injury or harm, just the potential for harm...

...Procedure:

...Considered High Risk...Continuous observation 1:1 (one to one), staff (nursing, sitter) are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times. Utilize the Frequent Observation Flow Sheet...or EHR (electronic health record) for documenting visual surveillance and observations. Assess the environment of care in patients room and complete the Safe Room Check List...


1. PI # 8 presented to the facility ED on 5/14/22 at 8:44 PM with a chief complaint of "SI...patient took 1/2 (half) bottle of Curevo (Alcohol) and 24-30 tabs (tablets) of Lunesta(medication used to treat insomnia) and 1 of Zoloft (medication used to treat depression).." at approximately 7:00 PM. Patient "...starting to slur speech..."

Review of the Triage Assessment dated 5/14/22 at 8:55 PM revealed documentation a C-SSRS was completed with the Assessed Suicide Risk Level of High risk for suicide and "Provider Notified:...(Provider Identified) 1:1 (one to one) continuous monitoring..."

Review of the Nursing Assessment dated 5/14/22 at 9:36 PM revealed documentation to refer to triage assessment.

Review of the ED Physician Note dated 5/14/22 at 9:38 PM revealed documentation of "patient states earlier today...had about a half a 5th (fifth) of Tequila and an unknown amount of Lunesta perhaps around 18 +/- (plus or minus). (He/She) is feeling suicidal...behavior/mood is pleasant, cooperative, affect is calm, oriented to person, place, time, situation, patient having thoughts of suicide. Drink a lot of alcohol and take too many sleeping pills...mentation: is normal..."

Review of the ED Physician Disposition Summary dated 5/14/22 at 10:14 PM revealed documentation PI # 8 left AMA, his/her symptoms were unchanged, condition was undetermined with a Diagnosis of Poisoning by Other Drugs, Medicaments and Biological Substances, Accidental (Unintentional) - Intentional Overdose of Sleeping pills in combination with alcohol.

Review of the AMA form dated 5/14/22 at 10:14 PM revealed documentation of the patient's signature with RN signature as a witness.

Review of the ED Nurse documentation dated 5/14/22 at 10:14 PM revealed the patient left AMA.

Review of the Patient Rounding ED Nurse documentation dated 5/14/22 at 10:23 PM revealed documentation the patient remains alert and oriented and wished to leave AMA, the ED Physician was notified, the patient's caregiver was notified the facility could not keep the patient against their will, the patient signed the AMA form and understood the risks of leaving along with being welcome to return should the patient change his/her mind.

Review of the ED Nurse documentation dated 5/14/22 at 10:27 PM, revealed a discharge assessment of "slurred speech improving...", patient alert and oriented with easy respirations, stands/transfers to wheelchair to private vehicle without issue, the caregiver was driving the patient home, the patient left AMA with risks explained and the patient signed AMA form.

Review of the ED Nurse documentation dated 5/14/22 at 10:29 PM, revealed PI # 8 left the ED.

Review of the MR revealed no documentation the facility staff encouraged PI # 8 to stay and be transferred to complete the MSE, PI # 8 was placed on one-to-one observation per facility policy, a room safety checklist was performed per facility policy and PI # 8 was reassessed for SI prior to discharge from the facility.

An interview was conducted on 9/22/22 at 11:25 AM with Employee Identifier # 1, ED Director, who confirmed there was no documentation the facility staff encouraged PI # 8 to stay and be transferred to complete the MSE, PI # 8 was placed on one-to-one observation per facility policy, a room safety checklist was performed per facility policy and PI # 8 was reassessed for SI prior to discharge from the facility.

Based on medical record reviews, Emergency Department Logs, Emergency Department Video footage, ED/Hospital Census, letter from the complainant, Policy and Procedure and staff interviews it was determined that the facility failed to offer further medical screening examination and treatment, and failed to explain to the individual the risks and benefits of leaving the without further examination and treatment.

This affected one of 21 sampled medical records including Patient #15.

Findings include:

The Emergency Medical Treatment and Active Labor Act (EMTALA) Policy version 4, Publish date 2/05/21 was reviewed. The section of the policy titled, "1. General EMTALA Obligations ..." "2. Documentation When A Patient Leaves Without Being Seen, Against Medical Advice, Without Notifying staff, revealed in part, "If a patient informs the ED registration staff that he/she is leaving prior to receiving Medical Screening Examination (MSE), ED staff should obtain the patient's signature, date and time on a "AMA" (Against Medical Advice) form or "Refusal of Care" form, indicating that they have been informed of the risks and benefits leaving the ED prior to receiving an MSE or prior to receiving stabilizing treatment for an EMC. If the patient refuses to sign the form, staff should document the circumstances of the refusal."

Review of a letter received, the complainant stated that he took Patient Identifier (PI) # 15 to the facility Emergency Department (ED), (Hospital A) on 8/11/22 and told the facility PI # 15 was going into Ketoacidosis with a blood sugar of 555 (normal blood sugar levels- 70 to 100) at home. After the arrival at the ED, the complainant documented PI # 15's condition worsened and after an hour of waiting without triage, PI # 15 could not walk, became nauseated and had a severe headache. The complainant documented he/she carried PI # 15 to a personal vehicle and transported PI # 15 to another facility, (Hospital B) where PI # 15 had a blood sugar of 689 and was admitted to the Intensive Care Unit (ICU) for two days.

Review of the facility ED log revealed PI # 15 presented to the ED on 8/12/22 at 10:20 PM.

Review of the ED Nurse Documentation dated 8/12/22 at 11:30 PM revealed documentation the patient's spouse complained to the ED registration about being at the ED for an hour and asked when they would be called back. The ED registration explained to the patient's spouse there were multiple ambulances and stats that had come in at the same time as the patient and the nurses were seeing patients as quickly as possible. The spouse then began to raise his/her voice. In response to the raised voice of PI # 15's spouse, the triage nurse went out and asked the spouse what was going on with PI # 15, to which the spouse continued to yell while walking out of the ED saying they would go to another facility. The nurse documented telling PI # 15 she/he could triage and check the blood sugar now, but the patient and spouse continued to walk out of the ED. PI # 15 was documented as left without being seen, prior to triage and provider evaluation.

Review of the ED Video Footage dated 8/12/22 from 10:21 PM to 11:43 PM revealed the following at:

10:21 PM: PI # 15 and spouse entered the facility ED.
10:21:31 PM: PI # 15 and spouse arrive at the ED registration desk and the patient sits down in chair.
10:27:11 PM: PI # 15 and spouse leave registration desk and walk to the bathroom.
10:31:40 PM: PI # 15 exits the bathroom. PI # 15 and spouse walk to the ED waiting area and sit down.
10:39:08 PM: The spouse stands and goes to the ED vending machine to obtain water. During this, PI # 15 stands up and removes jacket then sits back down.
10:40:36 PM: The spouse returns to PI # 15, hands him/her a bottle of water, then sits down. PI # 15 and spouse remain seated in the waiting room. At times PI # 15 would lay her/his head on the spouse's shoulder and also bend over (seated position) and place head in her/his hands.
11:17:00 PM: The spouse stands up and walks to the registration desk. The patient remains seated in the waiting area.
11:17:13 PM: The spouse appears to be speaking with Employee Identifier (EI) # 2, Registration clerk.
11:17:37 PM: The spouse walks back to PI # 15 and sits down in the waiting area.
11:27:10 PM: PI # 15 and spouse stand up and walk to bathroom. Both enter bathroom.
11:29:47 PM: PI # 15 and spouse exit bathroom, return to the ED waiting area and sit down.
11:40:10 PM: PI # 15 and spouse stand up and walk to the registration desk. The spouse appears to talk with EI # 2.
11:40:51 PM: PI # 15 sits at the registration desk.
11:41:17 PM: PI # 15 stands up and both PI # 15 and spouse walk towards the ED exit door.
11:41:28 PM: PI # 15 and spouse stop, and the patient returns to the registration desk then sits down.
11:41:31 PM: The spouse turns and walks out of the ED exit door. PI # 15 remains seated at the registration desk.
11:43:29 PM: The spouse returns to the ED and walks up to PI # 15 seated at registration desk.
11:43:36 PM: The spouse assists PI # 15 to stand, and both start walking toward the ED exit door with the spouse holding on to PI # 15 by the arm. At the same time, EI # 3, Registered Nurse (RN), Triage Nurse, is observed coming out of the triage room door and walking toward PI # 15 and spouse.
11:43:41 PM: PI # 15 and spouse stop and turn toward EI # 3 and the spouse appears to talk.
11:43:43 PM: The spouse raises his/her hand and arm in the air, while appearing to talk and starting to again, walk with the patient. PI # 15 and spouse exit the ED.
11:43:49 PM: EI # 3 enters the triage room.

ED/Hospital Census:

Review of the ED Census on 8/12/22 from 10:21 PM to 11:43 PM revealed:

Sixteen of the twenty-one ED beds were occupied, and six beds were closed due to staffing when PI # 15 presented to the ED.
Four additional ED beds were closed after the occupying patient was discharged to maintain staffing due to staff ending shift(s) during PI # 15's ED visit.
The ED was at normal staffing with the ED exam room closures.
Five of the sixteen occupied beds were patients who arrived via EMS prior to PI # 15 presenting to the ED with arrival times documented at: 3:44 PM, 4:43 PM, 8:44 PM, 9:26 PM, 10:12 PM and 10:16 PM.
One patient arrived via EMS following PI # 15's presentation to the ED at 11:09 PM, with Breathing Difficulty and the patient was placed in exam room 7.
Two patients were placed in ED beds who arrived via private vehicle to include: A dependent, mute patient who arrived prior to PI # 15 with COVID/Flu symptoms and a patient who arrived after PI # 15 with Shortness of Breath and High Blood Pressure.

Review of the facility ICU beds on 8/12/22 from 10:21 PM to 11:43 PM revealed the facility had five ICU bed open and available with normal staffing.

Review of the ED Stats list for triage revealed no documentation of high blood sugar and/or complaint of possible Diabetic Ketoacidosis (DKA) as a stat for triage.

Hospital B Documentation:

Review of Hospital B's, Receiving Facility, ED Provider Note dated 8/13/22 at 12:14 AM revealed documentation PI # 15 presented to the ED with concerns for DKA, with a glucose reading over 600 on evaluation, nausea, headache, generalized weakness, dry mouth, some shortness of breath, felt a little bit lightheaded and DKA was suspected. Further review revealed PI # 15 had an insulin pump of which the tubing was changed the night prior and PI # 15 did have a malfunction in the sensor this evening for about 2 hours, when the sensor started reading again it just said high so the patient was brought to the ED.

Review of the Laboratory results dated 8/13/22 revealed documentation at 12:51 AM a Point of Care Glucose was performed with result of above 600 and at 1:07 AM a Comprehensive Metabolic Panel was collected which resulted in a Glucose of 698, a high panic value, CO2 (Carbon dioxide) 14, a low panic value, sodium 127, a low value, BUN (blood urea nitrogen), 26, a high value and a osmolality calculation 294, a high value.

Review of the Discharge Summary dated 8/15/22 revealed PI # 15 was admitted to PCU (Progressive Care Unit) then transferred to a floor for DKA and was treated with intravenous fluids, insulin and the patient's acidosis was corrected. PI # 15 was discharged in good condition on 8/15/22 from Hospital B.

Interviews:

An interview was conducted on 9/22/22 at 9:30 AM with EI # 2, ED Registration Clerk, who could not recall PI # 15 but verbalized when a patient presents to the ED registration desk the clerk will ask for the patient's identification then go ahead and grab a nurse and let them know what's going on. EI # 2 verbalized if a patient presents with a high blood sugar the registration clerk does not document the number, because it could be a HIPPA (Health Insurance Portability and Accountability Act) violation, but the patient's do "...normally tell me the number if it's high or low and I tell the nurse..."

An interview was conducted on 9/22/22 at 10:03 AM with EI # 3, ED Registered Nurse, who verbalized patients are triaged based on a list of "stats" and "...to my knowledge, high blood sugar, is not on the list and the patient we are talking about did not sign in with a complaint of Diabetic Ketoacidosis (DKA)..." EI # 3 verbalized she/he was informed of PI # 15 "...when the patient's spouse began to yell and berate our registration clerk. To my knowledge they didn't tell our registration they were having any symptoms on our stat list, no dizziness, shortness of breath, or other symptoms were reported to registration except high blood sugar. To my knowledge they never mentioned DKA to registration." EI # 3 verbalized she/he went out and talked with PI # 15 and the spouse and told them she/he would be happy to take the patient to triage and check the blood sugar, but the spouse refused and said they were going to another facility. EI # 3 further verbalized the patient had not appeared in any distress, walking into the facility, and going back and forth to the bathroom several times. EI # 3 verbalized she/he did not explain the risks and benefits of staying for the completion of the Medical Screening Exam due to the patient's spouse yelling they were going to another facility and would not allow the facility staff to do anything. Following the interview, EI # 3 returned a call to the surveyor on 9/22/22 at 10:22 AM to provide additional information as follows: "We did talk about what is considered a stat in ED. During the time they did come in we had two stats come in and two EMS (Emergency Medical Services) come in. So, we did have four that signed in for life threatening emergencies. So, I was running between triage and EMS triage. It was just extremely busy and there were several patients that were in distress. I believe shortly after I took the shortness of breath from the lobby to triage, which is an emergency, that's when he became frustrated and started yelling at the staff."

An interview was conducted on 9/22/22 at 11:23 AM with EI #1, ED Director. A question was asked by the surveyor, "Is there documentation the nurse explained the Risks/Benefits of staying for the completion of the Medical Screening Exam (examination) to the pt. (patient) and/or caregiver?" The ED Director replied, "No, it is not documented, the husband was yelling walking out of the doors, ...".

An interview was conducted on 9/22/22 at 2:23 PM with EI # 1, ED Director, who verbalized it is not standard for the registration clerk to document the blood sugar reading if it is provided by the patient at registration. The registration clerk will tell the patient to have a seat and the nurse will be with them. EI # 1 verbalized the triage nurse provides triage according to what is present in the ED at the time of the patient's arrival and "if there is a chest pain, shortness of breath, stats, then the triage nurse will pull those first." EI # 1 verbalized a high blood sugar and/or DKA in not considered a stat for triage at the facility. EI # 1 verbalized he/she was not present during PI # 15's visit to the ED but did perform an investigation where she spoke with the triage nurse "...who said they were dealing with multiple EMS and triage stats" and while triaging another patient the registration clerk notified the triage nurse a patient's spouse was upset to which the triage nurse said to let them know she/he would be out to triage them as soon as the current patient was finished with triage. EI # 1 further verbalized the triage nurse said the clerk had reported a blood sugar in the 200's and when the nurse went out to the patient the spouse was yelling at the registration staff and the triage nurse notified the patient and spouse she/he would triage the patient now, the patient and spouse continued to walk out the doors, saying the spouse would take the patient to a different hospital.

The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to explain the risks and benefits of leaving the ED prior to an MSE or prior to receiving stabilizing treatment for an identified EMC.