HospitalInspections.org

Based on review of the facility policies, medical records, Hospital # 1's Final Census Reports, Hospital # 1's Daily Time Reports and interviews, it was determined the facility failed to:
1. Provide a medical screening examination (MSE), stabilizing treatment and ensure stabilizing treatment was not delayed on 1/23/17 for Patient Identifier (PI) # 1, a psychiatrically unstable patient who presented to the facility's Emergency Department (ED) on 1/23/17 at 2:49 PM. PI # 1 did not have a representative available until the patient's daughter arrived several hours later. PI # 1 signed an Against Medical Advice (AMA) form prior to the daughter's arrival. Once the patient's daughter arrived, she requested the patient to be re-evaluated by the physician, which was not completed. The patient left with the daughter. PI # 1 presented to Hospital # 2's Emergency Department (ED) on 1/24/17 (following day), was medically screened and appropriately transferred to Hospital # 3 for inpatient psychiatric treatment.

2. Provide an appropriate MSE, stabilizing treatment and ensure stabilizing treatment was not delayed for PI # 2, a patient who presented to the facility's ED on 6/29/16 with acute psychosis and hallucinations. There was no documentation the ED physician or the ED staff attempted to contact the Geriatric Psychiatric Unit (GPU) or psychiatrist for further medical screening examination of the patient's psychiatric symptoms. The facility had the capacity and capability to treat PI # 2, but the patient was transferred to an inpatient psychiatric unit at Hospital # 3 on 6/29/16, thus delaying the patient's stabilizing treatment.


Findings include:

Refer to findings at A2406, A2407, A2408 and A2409.

Based on review of facility policy, medical records and interviews, it was determined the facility failed to provide a medical screening examination (MSE) on 1/23/17 for Patient Identifier (PI) # 1, a psychiatrically unstable patient who presented to the facility's Emergency Department (ED) on 1/23/17 at 2:49 PM. PI # 1 did not have a representative available until the patient's daughter arrived several hours later. PI # 1 signed an Against Medical Advice (AMA) form prior to the daughter's arrival. Once the daughter arrived, she requested the patient to be re-evaluated by the physician, which was not completed. The patient left with the daughter. PI # 1 presented to Hospital # 2's Emergency Department (ED) on the morning of 1/24/17, was medically screened and appropriately transferred to a psychiatric unit at Hospital # 3.

This also affected Patient Identifier (PI) # 2, a patient who presented to the facility's ED on 6/29/16 with acute psychosis and hallucinations. There was no documentation the ED physician or the ED staff attempted to contact the GPU or psychiatrist for further screening examination of the patient's psychiatric symptoms. The patient was transferred to an inpatient psychiatric unit at Hospital # 3 on 6/29/16.

This affected 2 of 21 medical records reviewed.

Findings include:

Facility Policy

Subject: EMTALA (Emergency Medical Treatment and Labor Act) for Emergency Department Services

Policy: All patients presenting to Grove Hill Memorial Hospital's (Hospital # 1) Emergency, Labor and Delivery or Psychiatric Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.

In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.

All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic...

Medical Screening Exams:

Medical Screening Exams should include at a minimum the following:

... Vitals signs

History

Physical exam of affected systems and potentially affected systems

Exam of known chronic conditions

Necessary testing to rule out emergency medical conditions

Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary...

Complete documentation of the medical screening exam...

Emergency Medical Conditions:

An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:

... Substance abuse symptoms, i.e., alcohol ingestion

Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, dis-associative state, inability to comprehend danger or care for self.

1. Patient Identifier (PI) # 1 presented to Hospital # 1's Emergency Department (ED) on 1/23/17 at 2:49 PM with chief complaints of "possibly took too much meds (medications) - accidental."

Review of the Triage Assessment dated 1/23/17 at 2:50 PM revealed the nurse documented the patient stated, "... feels like (he/she) is going to hurt (him/herself) or someone else. Very cooperative..." Review of the nursing assessment revealed the patient was confused and anxious.

Review of the Emergency Physician Record dated 1/23/17 at 3:10 PM, the physician documented the patient's chief complaint of confusion earlier today. The physician documented the patient was alert and oriented times 4 (person, place, times and situation/recent events). The patient's social history was positive for THC (Tetrahydrocannabinol) and the physician documented questionable tainted marijuana.

The physician documented the patient's physical exam included the following signs/symptoms:
anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations.

Review of the medical record revealed laboratory tests were performed with the following abnormal results:

Theophylline level - 1 ug/ml (micrograms/milliliter) (low) (normal for this facility 10 - 20)

Comprehensive Metabolic Panel (CMP)

BUN (blood urea nitrogen) - 59 mg/dl (milligrams/deciliter) (high) (normal for this facility 5 - 22) (BUN test measures the amount of nitrogen in your blood that comes from the waste product urea and is done to see how well your kidneys are working. www.webmd.com)

Creatinine 1.76 mg/dl (normal for this facility 0.6 - 1.20) (high) (Creatinine measures the level of the waste product creatinine in your blood and urine. These tests tell how well your kidneys are working. www.webmd.com)

BUN/Creatinine (ratio) 34 (normal for this facility 8 - 20) (high) (BUN/Creatinine ratio is used in the differential diagnosis of acute or chronic renal disease and may also be due to a condition that results in decreased blood flow to the kidneys, such as congestive heart failure, shock, stress, recent heart attack, or severe burns, to conditions that cause obstruction of urine flow, or to dehydration. www.labtestsonline.org)

SGOT/AST 101 (normal for this facility 9-37) (high) (serum glutamic oxaloacetic transaminase (SGOT)/aspartate aminotransferase (AST) test measures the amount of this enzyme in the blood. AST is normally found in red blood cells, liver, heart, muscle tissue, pancreas, and kidneys. AST formerly was called serum glutamic oxaloacetic transaminase. www.webmd.com)

SGPT/APT 57 (normal for this facility 5 - 43) (high) (serum glutamic-pyruvic transaminase (SGPT)/ alanine aminotransferase (APT) test measures the amount of this enzyme in the blood. ALT is found mainly in the liver, but also in smaller amounts in the kidneys , heart, muscles, and pancreas . ALT was formerly called serum glutamic pyruvic transaminase.)

Urinalysis results:

Ketone 1+ (normal for this facility is negative) (Ketone is a chemical produced when there is a shortage of insulin in the blood and the body breaks down body fat for energy. www.diabetes.org)

Urine drug screen:

THC (tetrahydrocannabinol) - positive (normal for this facility is negative) (tetrahydrocannabinol (THC) is the active principle of cannabis www.medical-dictonary.thefreedictionary.com)

Review of the medical record dated 1/23/17 revealed the following nursing documentation:

3:30 PM - the patient felt very anxious and that he/she may harm self or others.

3:35 PM - police were called to sit with patient and that he/she was cooperative at that time.

3:50 PM - Geodon 20 mg (milligrams) was administered IM (intramuscularly). (Geodon is an antipsychotic medication. Geodon (ziprasidone) administered intramuscular administration of single doses, peak serum concentrations typically occur at approximately 60 minutes post-dose or earlier and the mean half-life ranges from two to five hours. www.rxlist.com)

4:00 PM - sheriff's deputy was at the patient's beside and the patient was cooperative at that time.

5:30 PM - patient's daughter was called, made aware of the patient's status and (the daughter) was en route to the hospital from another town (several hours drive from the location of the hospital).

Review of the Emergency Physician Record dated 1/23/17 at 6:55 PM revealed the physician documented the patient was re-examined and the patient's condition was improved. The physician further documented having discussed with the patient admission to the hospital which the patient declined and "... will sign out (Against Medical Advice) AMA..."

Review of the medical record dated 1/23/17 at 7:20 PM revealed the nurse documented the physician spoke with the patient about admission to the hospital, the patient declined admission at that time and signed out AMA.

Review of the Release of Grove Hill Memorial Hospital and Physicians of Responsibility Withdrawal of Request for Care dated 1/23/17 revealed the physician signed at 7:15 PM, and the patient and nurse signed at 7:20 PM.

Review of the Emergency Physician Record dated 1/23/17 revealed the physician documented the patient's disposition was marked "discharge" at 7:30 PM in an improved, stable condition.

Review of the late entry documentation dated 1/23/17 and signed on 2/7/17 by Employee Identifier (EI) # 2, Mental Health Liaison/Psychological Counselor revealed, "... Was called to ER (Emergency Room) lobby due to patient presenting with confusion... encountered (patient) sitting, slightly agitated and looking confused. (Patient) was asked to tell this writer what (he/she) needed and... responded, "I need help, why do you think I am here"... registered as ER patient and taken to Trauma room 2... (Patient) displayed rapid speech and confused thinking... Patient was very needy and wanted someone sitting in the room ... at all times. After labs came back... admitting psychiatrist was called to get placement on the GPU (Geri-psychiatric unit) at this hospital. The doctor refused to take patient for admission due to (patient) not having a history of mental illness... talked to patient's daughter... (daughter informed EI # 2) her aunt (EI # 8, Registered Nurse - Labor & Delivery) worked at our hospital... (EI # 8) was brought to patient bedside and patient calmed and talked to her but still with rapid speech. Patient daughter told nurse that she did not want patient sent anywhere until she arrived. I left and advised if daughter wanted patient placed I would come back to hospital and take care of this for them. Did not receive a call to return and was told the next morning that the patient signed... out AMA... This is a late entry as I thought I would be placing patient later the same night..."

Review of the medical record from Hospital # 2 revealed the patient presented to Hospital # 2's Emergency Department (ED) on 1/24/17 at 10:42 AM with chief complaint of paranoia and hallucinations which were progressively worse over the last two weeks with no history of mental disorder.

Review of Hospital # 2's Emergency Nursing Record dated 1/24/17 at 10:42 AM revealed the nurse documented the patient had anxiety, sleeping difficulty, hostility, confusion and was having auditory and visual hallucinations.

Review of Hospital # 2's ED record revealed the medical screening examination (MSE) was performed by the physician on 1/24/17 at 11:30 AM. The following tests were performed: Complete Blood count (CBC), Urinalysis, Basic Metabolic Panel (BMP), Thyroid stimulating hormone, urine drug screen, Tylenol level, Salicylate level, alcohol level EKG (electrocardiogram) and chest x-ray.

Review of the Mental Health Consultation form dated 1/24/17 at 1:46 PM revealed, "... Client presented to ER( Emergency Room). c/o (complaints of) paranoid thoughts, poor sleeping habits... admitted to paranoid thoughts/ A-H (auditory hallucinations) "warning (him/her) lack of sleep and appetite. admitted to THC (tetrahydrocannabinol) used, and past alcohol abuse. Client agreed to voluntary placement..."

Hospital # 2 arranged for an appropriate transfer to Hospital # 3 on 1/24/17 at 5:50 PM.

Review of Hospital # 3's medical records revealed the patient was admitted on 1/24/17 at 8:16 PM with diagnosis of Psychosis.

Review of the Senior Behavioral Health Psychiatric Evaluation (Admission) dated 1/25/17 revealed the patient's chief complaint was psychosis. The physician documented, "... Per review of nursing notes on admission... Daughter reports that pt (patient) lives alone...has been politically fixated, since the election... behavior has escalated... has paper plates and papers with messages written on them taped to the floor and walls near the couch where... has been sleeping. Reportedly been stating "I'm connecting. I'm linking all of this. I've got connections." Reportedly paranoid about the government and making statements about the Nazi's and thinks the CIA (Central Intelligence Agency) is after (him/her)... Reportedly pt drove... to (Hospital # 1) " to get help" today... Reportedly while in the ED at that facility pt told nursing staff to handcuff (him/her) to the gurney, that voices were telling (he/she) might hurt somebody or hurt (self)...

It is somewhat unclear regarding the patient's psychiatric history. The patient is floridly psychotic (This term is used to mean that the psychosis is in full bloom, which is another way of saying that the afflicted's lost touch with our generally shared reality. www.quora.com)... has some elements of mania as well. Patient appears very grandiose paranoid simultaneously... has been responding to internal stimuli or actively hallucinating at times at home... disorganized in (his/her) thoughts and speech except... does say ... has been diagnosed with some mental condition and has seen multiple psychiatrists over the last 40 years... has been on medication in the past for... mental illness although he/she cannot remember any by name... the patient also reports that he/she is not feeling right and that he/she knows he/she is out of touch with reality. He/she is not currently prescribed any psychotic medications per review of his/her home medication list...

Mental Status Examination:
Mood: Anxious, elevated and irritable
Affect: Irritable, labile and expansive
Cognition: STM (short term memory) poor, concentration - moderately impaired...
Thought Process: ... Racing thoughts and pressured speech
Thought Content: Auditory hallucinations - present, Delusions - present, Ruminations and obsessions (Rumination means simply repetitively going over a thought or a problem without completion. www.psychologytoday.com)
Insight and Judgement: adequate...

Multi-axial diagnosis:
Axis I: Unspecified psychotic disorder, rule out schizophrenia, rule out bipolar type I disorder most recent episode manic with psychotic features, cannabis use disorder, alcohol use disorder (remission)...

Plan:
1. Admit (patient) to Hospital # 3 psychiatry...

Estimated length of stay: 14 days...

Review of Hospital # 3's Psychiatric Discharge Summary dated 2/2/17 revealed the following:

Discharge Summary:
Axis I: Unspecified psychotic disorder, cannabis use disorder, alcohol use disorder (remission)...

Reason for Admission: Psychosis...

Hospital Course:

... During this hospitalization patient was slowly titrated to an effective dose on Risperdal for active symptoms of psychosis... also started on Cogentin for EPS (extrapyramidal side effects) prophylaxis... started on low-dose Zoloft for symptoms of anxiety and titrated to an effective dose by the time of discharge... His/her very florid symptoms of psychosis seemed to respond rapidly to the antipsychotic medication. At no time did it ever seem that the patient suffered from a delirium or clear medical condition as a constricting factor of his/her psychosis. Note a cannabis-related psychotic disorder seemed unlikely. It is possible that the patient suffers from a primary psychosis such as schizophrenia or schizoaffective disorder, or a major mood disorder with psychotic features such as bipolar type I disorder... at the time of discharge patient's mood seemed stable... denied symptoms of depression... denied suicidal or homicidal ideations plans or intents... did not seem manic nor did (he/she) seem overtly psychotic...

Discharge Plan: Disposition: Assisted-living facility...

The patient's discharge medications included: Cogentin 1 mg (milligram) every day, Risperdal 4 mg every day and Zoloft 100 mg every day.

Interview conducted on 2/7/17 at 12:40 PM with Employee Identifier (EI) # 1, Emergency Department (ED) Physician (Hospital # 1) on duty during the day time on 1/23/17, when PI # 1 presented to the ED. EI # 1 verified he remembered PI # 1. EI # 1 stated that he stated he was in with another patient and he heard yelling from triage and went to see the patient.

EI # 1 stated the patient was anxious and psychotic and this seemed new for the patient. He stated patient was agitated, had flight of ideas, but was alert. Neurological status was intact and the patient did not smell of alcohol. EI # 1 stated the patient's assessment was unremarkable. While in ED, the patient's urine drug screen was completed and tested positive for cannabis. EI # 1 stated he thought the patient had gotten a hold of some "bad pot." The patient was anxious, yelling and was medicated with Geodon, which seemed to have calmed the patient down. He stated they contacted EI # 2, Mental Health Liaison/Psychological Counselor to come see the patient.

EI # 1 stated he talked with the patient about admission, but the patient refused and wanted to go home. EI # 1 stated the nurse explained to the patient about signing Against Medical Advice (AMA) and the patient said he/she wanted to leave. EI # 1 stated after Geodon was administered, the patient dramatically improved with no lingering effects from it. EI # 1 stated he had no concerns with him leaving AMA. He was stable.

EI # 1 stated that EI # 2 told him that she spoke with the patient and the patient had no history of mental illness and the GPU (Geripsych unit) doctor (EI # 4, Psychiatrist) was called. He stated he was told the psych doctor was not inclined to admit the patient to the GPU.

EI # 1 stated he knew the daughter was on her way to the hospital and was not sure how she would feel about our decision to release him AMA, but the patient was stable. He stated when he left at 7:30 PM and the daughter was still not at the facility.

Interview with EI # 3, Registered Nurse (RN) on 2/7/17 at 1:21 PM. EI # 3 was working in the ED on the day PI # 1 arrived. EI # 3 stated when she saw the patient drive by in his/her car, the patient came into the hospital and wanted to talk to an RN. I talked with the patient who wanted to be hand cuffed to the chair because he/she felt like he/she would hurt him/herself or someone else. The patient then went through triage and was very cooperative with the assessment. The patient stated as long as he/she was talking to someone he/she felt okay. The patient asked me to call the police and I did because, he/she was so anxious. The police came to the hospital and sat with the patient. The patient was very anxious at this time, but cooperative.

EI # 3 stated the patient was restless and anxious. Lab personnel came and drew the labs without a problem. The patient was medicated with Geodon, he/she rested after that and said he/she felt better.

EI # 3 stated she called and spoke with the patient's daughter. EI # 3 stated the daughter said that she lives in a town (approximately 3 hours away). The daughter said she felt like the patient watched too much news and that's the reason for the behavior.

EI # 3 stated EI # 1 wanted the patient to sign out Against Medical Advice (AMA), because the patient refused to be admitted. EI # 3 stated she told the on coming shift the patient signed out AMA, but was in the room waiting for his/her daughter to arrive. I thought maybe the daughter could get the patient to stay and be admitted to the hospital.

EI # 3 stated that EI # 2, Mental Health Liaison/Psychological Counselor came to see the patient for a mental health consult because the patient was saying he/she needed help, but would not say what kind of help he/she needed. EI # 3 stated when she left, the patient's daughter had not arrived at the hospital, so she did not get a chance to talk to her.

When questioned about the patient's condition at the end of her shift, she stated that the patient was very different from when he/she came in. The patient was calm after the Geodon and when the patient came into ED, he/she was very anxious and confused.

Interview with EI # 2, Mental Health Liaison/ Psychological Counselor on 2/7/17 at 1:52 PM.
EI # 2 verified she recalled PI # 1. She stated she received a call and went to the ED. The patient was in the ED admission waiting room. I got the patient registered. I then took the patient to trauma room # 2 and assisted to the bed. I asked the patient about his/her medications, but the patient could not remember, so the drug store was called. The patient was taking Theophylline, so a Theophylline level was drawn and it was fine. They also did a urine drug screen.

EI # 2 stated the patient told one of the RNs that he/she needed someone with him/her or he/she would hurt someone, so the police were called. EI # 2 stated she called the patient's daughter and described to her what was going on with the patient. The daughter said "... does not sound like him/her." The daughter requested us not send the patient anywhere until she arrived which was 3 hours away.

EI # 2 stated she contacted EI # 4, Psychiatrist and he said he would not take the patient. "I am not taking him." EI # 2 stated she was not sure why he would not take the patient.

EI # 2 stated that after the patient calmed down and knew the patient's daughter was on her way, she left for the day. She stated that she told the ED staff to call her for placement. She stated she never received a call from the hospital.

When questioned about the difference in the patient from the time he/she came in until the time she left for the day, EI # 2 responded by saying the patient was manic when he/she first came to the ED, would not be still and would not listen. She said the patient's speech was rapid, confused and delusional. She stated by the time she left the patient was comfortable, laughing, had eaten and then took a nap.

When asked if she thought the patient could make a decision on his/her own for example to sign out AMA she said "... I don't know. I would not have left it up to him/her what to do because, it was all brand new. The daughter said to wait till she got there and that's what she wanted."

An interview was conducted on 2/8/17 at 8:30 AM with Employee Identifier (EI) # 5, RN. EI # 5 was working in the ED on the evening shift 1/23/17. EI # 5 denies remembering PI # 1, but did remember the patient's daughter. EI # 5 stated the patient's daughter was yelling at (EI # 5) and said she wanted the doctor to see the patient. EI # 5 stated she told EI # 6, ED Physician, who stated he would not get involved with it. EI # 5 stated she told the daughter that EI # 6 was not going to see the patient.

An interview was conducted on 2/8/17 at 8:50 AM with EI # 7, Licensed Practical Nurse, who verified she remembered the patient. She stated she briefly took care of the patient before the patient's daughter arrived. She stated the patient was in bed and calm at that time.

When questioned if she had spoken with the patient's daughter, EI # 7 stated "yes." EI # 7 stated she told the patient's daughter that the patient was discharged. She stated the patient's daughter became upset and said she wanted the patient to be re-evaluated. She stated that was when EI # 5, RN talked with EI # 6, ED Physician (assigned to ED after 7 pm).

Interview conducted on 2/8/17 at 11:46 AM with Employee Identifier (EI) # 6, ED Physician assigned to the ED after 7:00 PM on 1/23/17, when PI # 1 was in the ED. EI # 6 verified he was assigned to the ED the night of 1/23/17. He stated he could not remember if he was asked to see the patient or asked to talk with the patient's daughter. EI # 6 verified he did not see the patient.

EI # 6 stated he had a patient in labor & delivery (L & D) at the time he was to report to the ED. EI # 6 stated when he went to the ED, EI # 1, ED Physician (day shift) was still present and he was able to go back to L & D to deliver the patient's baby. He stated that while in L & D, EI # 8, Registered Nurse (RN) L & D (PI # 1's former sister in law) kept asking him if he had seen the patient. EI # 6 told her that when he finished with delivery, he would go check the patient. He stated when delivery was completed, he went back to the ED and the patient was already gone.

Summary: According to the (EI # 1) ED Physician's documentation on 1/23/17, PI # 1 presented to the hospital with anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations. Geodon was administered to the patient, which was effective in calming the patient. According to the physician, admission was discussed with the patient, who refused.

The patient's daughter was contacted and was en route to the hospital. Once the patient's daughter arrived, she requested the patient be re-evaluated. According to the interview with EI # 5, RN; she informed EI # 6, ED Physician about the daughter's request for the patient to be re-evaluated, at which time EI # 6 refused. According to interviews, the patient's ex-sister in law requested EI # 6, ED Physician to assess the patient. Once EI # 6 finished with the delivery of a patient's baby, EI # 6 returned to the ED and the patient had already left the facility.

The request for the patient to be re-evaluated were not completed. The patient presented to Hospital # 2 on 1/24/17 (following day) due to continued symptoms and was appropriately transferred to Hospital # 3's inpatient psychiatric unit.


2. PI # 2 presented to the facility's ED with family on 6/29/16 at 12:54 PM with chief complaint of Hallucinations and "talking out of head."

Review of the Nursing Assessment documentation dated 6/29/16 revealed the following nursing documentation:

1:30 PM - "... Pt to ER (Emergency Room) triage done. Unable to obtain vital signs at this time due to hostile. Family in with patient. Holding (him/her) down and trying to talk (him/her) into staying in ER. Pt yelling and cussing at this time..."

1:50 PM - "... EI (EI) # 2, Mental Health Liaison/Psychological Counselor called... (Local) police called..."

2:05 PM - "... Geodon (20 mg) given IM... pt allowed vital signs to be obtained..."

Review of the Emergency Physician Record dated 6/29/16 revealed the physician performed the Medical Screening Exam (MSE) at 2:15 PM. The physician documented the chief complaint was acute psychosis, the patient was moderately to severely agitated with an onset of 3 days prior to presentation to the ED. The patient's history of illness in relation to onset, triggers, etc... were very poor and vague. Associated symptoms included frustration, agitation, hostility and confusion with questionable hallucinations. The patient's past medical history included acute psychosis on 2 occasions in the past 2 to 3 years.

The patient's physical examination indicated the patient was moderately to severely distressed, acutely psychotic, "somewhat" agitated and anxious. The patient's speech was rambling and disjointed.

Review of the Focus Notes dated 6/29/16 revealed the nurse documented the following:

4:30 PM - "... Transfer to Hospital # 4 in progress pending acceptance..."

5:30 PM - "... Pt (patient) up with family... unable to be transferred to Hospital # 4 d/t (due to) electrical problems... Pt to be transferred via ambulance to Hospital # 3 once room assignment given..."

6:15 PM - "... Pt accepted to Hospital # 3..."

6:45 PM - Geodon 20 mg (milligrams) IM (intramuscularly) given due to pt starting to get upset again..."

7:15 PM - "... Pt transferred via ASAP (as soon as possible) ambulance to Hospital # 3. No distress noted..."

Review of PI # 2's medical record from Hospital # 3 revealed:

Admission History and Physical dated 6/30/16

... History of Present Illness: "... On interview today patient is lying down in (his/her) room... is very somnolent after receiving another Haldol, Benadryl, Ativan... since arriving here to the unit due to agitated behaviors... awakens briefly but... thought and speech are very disorganized... will make incoherent statements such as "all day and all night." Therefore I interviewed (spouse) for majority of (his/her) history... (Spouse) denies any known mental illness or family history of mental problems... reports acute onset of psychosis with a shot (patient) received for arthritis. Upon clarification ... most likely a corticosteroid injection... reports this was on 6/22... (patient's) thoughts mood and behaviors have worsened since that time developing into a psychotic mania most likely corticosteroid-induced although... may have an underlying bipolar disorder simply undiagnosed and be very susceptible... (patient) had a brain injury in motor vehicle accident in 1982 but without severe deficits... denies history of any recent falls or seizures... denies (patient) uses alcohol or drugs. Urine tox (toxicity) at outside hospital was negative for all substances including alcohol..."

"... Psychiatric History: (Spouse) denies any inpatient psychiatric hospitalizations, outpatient psychiatric care or history of suicide attempts..."

"Multiaxial Diagnosis: Axis I: unspecified psychotic disorder, rule out corticosteroid-induced psychosis/mania, rule out bipolar type I disorder manic with psychotic features, mild cognitive impairment due to traumatic brain injury...

Plan: 1. Admit (patient) to Hospital # 3's psychiatry...Estimated length of stay: 14 days..."

Review of the Discharge Summary dated 7/1/16 revealed the following:

"... Discharge Summary: Axis I. corticosteroid-induced psychotic disorder, mild cognitive impairment due to traumatic brain injury... Reason for admission: Acute disturbance of thought mood and behavior specifically aggression..."

"... During this hospitalization patient was thoroughly evaluated... past history and current symptoms were reviewed in detail... It appeared that the patient had received a corticosteroid injection for arthritis that was the precipitation of this psychosis/mania... (patient) had no prior history of any psychiatric illness nor any family history of mental problems... patient was started on Depakote for disturbance of mood as well as agitation prophylaxis... has history of traumatic brain injury and therefore is more susceptible to emotional disturbance as well as potentially seizures... tolerated this medication well... quickly stabilized on the ward and did not show any signs of aggression at the time of discharge... At the time of discharge (patient) was pleasant... not manic nor psychotic... denied suicidal homicidal or violent ideations plans or intent...An extensive safety review plan was discussed with patient and (spouse) who both verbalized an understanding..."

"Discharge Plan: Disposition: Home..."

An interview was conducted on 2/8/17 at 10:47 AM with Employee Identifier (EI) # 9, Registered Nurse (RN), who was present on 6/29/16 when PI # 2 presented to the Emergency Department (ED).

EI # 9 verified she remembered PI # 2. She stated the patient's family brought the patient in. The patient was getting upset, jumped off the exam table and lunged at her. She stated the police had to be called due to the patient's aggressive behavior. A police officer came and stayed with the patient for about 2 hours.

EI # 9 stated the patient had been at Hospital # 4 and we called them for transfer. They were told they were unable to admit the patient due to power outage and they assisted with getting the patient admitted to Hospital # 3.

When questioned if Hospital # 1's GPU had been called and asked to come to evaluate the patient for admission, she stated that she did not recall.

EI # 9 verified the nurse completes the Transfer form and the documented reason for transfer was "Service not available" at Grove Hill Memorial Hospital. When questioned why services were not available in the GPU at Grove Hill Memorial Hospital. She stated she was not sure.

Summary:
According to PI # 2's medical record documentation, the patient met admission criteria for the Geriatric Psych Unit (GPU); in that, the patient was 55 years of age and was displaying psychotic behavior. There was no documentation the ED physician or the ED staff attempted to contact the GPU or psychiatrist for further screening examination of the patient's psychiatric symptoms. There was no documentation the patient/caregiver requested for the patient to be transferred to Hospital # 3.

Based on review of facility policies, medical records, Hospital # 1's Final Census Reports, Hospital # 1's Daily Time Reports and interviews, it was determined the facility failed to provide stabilizing treatment for 2 of 21 records reviewed.

This affected Patient Identifier (PI) # 1, a psychiatrically unstable patient who presented to the facility's Emergency Department (ED) on 1/23/17 at 2:49 PM. PI # 1 did not have a representative available until the patient's daughter arrived several hours later. PI # 1 signed an Against Medical Advice (AMA) form prior to the daughter's arrival. Once the daughter arrived, she requested the patient to be re-evaluated by the physician, which was not completed.

The patient left with the daughter. PI # 1 presented to Hospital # 2's Emergency Department (ED) on 1/24/17 (following day), was medically screened and appropriately transferred to Hospital # 3's for inpatient psychiatric treatment.

This also affected PI # 2, a patient who presented to the facility's ED on 6/29/16 with acute psychosis and hallucinations. The facility had the capacity and capability to treat PI # 2, but the patient was transferred to an inpatient psychiatric unit at Hospital # 3 on 6/29/16.


Findings include:

Facility Policy

Subject: EMTALA (Emergency Medical Treatment and Labor Act) for Emergency Department Services

Policy: All patients presenting to Grove Hill Memorial Hospital's (Hospital # 1) Emergency, Labor and Delivery or Psychiatric Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.

In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.

All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic...

Grove Hill Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA...

Grove Hill Memorial Hospital may not transfer patients who are potentially unstable as long as the hospital had the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity.

If a patient is to be transferred for medical necessity the following guidelines must be followed:

A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or

The patient requests a transfer in writing...

Emergency Medical Conditions:

An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:

... Substance abuse symptoms, i.e., alcohol ingestion

Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, dis-associative state, inability to comprehend danger or care for self.

Facility Policy:
Southern Oaks Grove Hill Memorial Hospital
Policy/Procedure # 1-01
Subject: Program Narrative

I. Purpose/Goals:

... D. To include provisions for the major diagnostic, medical psychiatric and psychosocial treatment modalities found in a comprehensive psychiatric inpatient program.

E. To provide a stable, therapeutic environment and a structured, supportive treatment program for diagnosis and treatment of acute psychiatric symptoms or decompensating clinical conditions that severely impair daily functioning...

II. Criteria for Admission:

A. The patient must be 55 years of age or older unless the individual has similar age-related issues.

B. The patient must have a provisional DSM V (Diagnostic and Statistical Manual of Mental Disorders) Axis I psychotic diagnosis.

C. The patient must be medically stable...

D. The patient must have received alternative (non-hospital) treatment without success or is exhibiting symptoms or behaviors that make alternative treatment inappropriate.

E. The patient must meet one or more of the following criteria to establish medical necessity for inpatient psychiatric care:

... 4. Is suffering from an acute onset or exacerbation of psychotic symptoms (hallucinations, delusions, disorganized thinking)...


1. Patient Identifier (PI) # 1 presented to Hospital # 1's Emergency Department (ED) on 1/23/17 at 2:49 PM with chief complaints of "possibly took too much meds (medications) - accidental."

Review of the Triage Assessment dated 1/23/17 at 2:50 PM revealed the nurse documented the patient stated, "... feels like (he/she) is going to hurt (him/herself) or someone else. Very cooperative..." Review of the nursing assessment revealed the patient was confused and anxious.

Review of the Emergency Physician Record dated 1/23/17 at 3:10 PM, the physician documented the patient's chief complaint of confusion earlier today. The physician documented the patient was alert and oriented times 4 (person, place, times and situation/recent events). The patient's social history was positive for THC (Tetrahydrocannabinol) and the physician documented questionable tainted marijuana.

The physician documented the patient's physical exam included the following signs/symptoms:
anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations.

Review of the medical record dated 1/23/17 revealed the following nursing documentation:

3:30 PM - the patient felt very anxious and that he/she may harm self or others.

3:35 PM - police were called to sit with patient and that he/she was cooperative at that time.

3:50 PM - Geodon 20 mg (milligrams) was administered IM (intramuscularly). (Geodon is an antipsychotic medication. Geodon (ziprasidone) administered intramuscular administration of single doses, peak serum concentrations typically occur at approximately 60 minutes post-dose or earlier and the mean half-life ranges from two to five hours. www.rxlist.com)

4:00 PM - sheriff's deputy was at the patient's beside and the patient was cooperative at that time.

5:30 PM - patient's daughter was called, made aware of the patient's status and that she was en route to the hospital from another town (several hours drive from the location of the hospital).

Review of the Emergency Physician Record dated 1/23/17 at 6:55 PM revealed the physician documented the patient was re-examined and the patient's condition was improved. The physician further documented having discussed with the patient admission to the hospital which the patient declined and "... will sign out AMA (against medical advice)..."

Review of the medical record dated 1/23/17 at 7:20 PM revealed the nurse documented the physician spoke with the patient about admission to the hospital, the patient declined admission at that time and signed out AMA.

Review of the Release of Grove Hill Memorial Hospital and Physicians of Responsibility Withdrawal of Request for Care dated 1/23/17 revealed the physician signed at 7:15 PM, and the patient and nurse signed at 7:20 PM.

Review of the Emergency Physician Record dated 1/23/17 revealed the physician documented the patient's disposition was marked "discharge" at 7:30 PM in an improved, stable condition.

Review of the late entry documentation dated 1/23/17 and signed on 2/7/17 by Employee Identifier (EI) # 2, Mental Health Liaison/Psychological Counselor revealed, "... Was called to ER (Emergency Room) lobby due to patient presenting with confusion... encountered (patient) sitting, slightly agitated and looking confused. (Patient) was asked to tell this writer what (he/she) needed and... responded, "I need help, why do you think I am here"... registered as ER patient and taken to Trauma room 2... (Patient) displayed rapid speech and confused thinking... Patient was very needy and wanted someone sitting in the room ... at all times. After labs came back... admitting psychiatrist was called to get placement on the GPU (Geri-psychiatric unit) at this hospital. The doctor refused to take patient for admission due to (patient) not having a history of mental illness... talked to patient's daughter... (daughter informed EI # 2) her aunt (EI # 8, Registered Nurse - Labor & Delivery) worked at our hospital... (EI # 8) was brought to patient bedside and patient calmed and talked to her but still with rapid speech. Patient daughter told nurse that she did not want patient sent anywhere until she arrived. I left and advised if daughter wanted patient placed I would come back to hospital and take care of this for them. Did not receive a call to return and was told the next morning that the patient signed... out AMA... This is a late entry as I thought I would be placing patient later the same night..."

Review of the medical record from Hospital # 2 revealed the patient presented to Hospital # 2's Emergency Department (ED) the following day, 1/24/17 at 10:42 AM with chief complaint of paranoia and hallucinations which were progressively worse over the last two weeks with no history of mental disorder.

Review of Hospital # 2's Emergency Nursing Record dated 1/24/17 at 10:42 AM revealed the nurse documented the patient had anxiety, sleeping difficulty, hostility, confusion and was having auditory and visual hallucinations.

Review of Hospital # 2's ED record revealed the medical screening examination (MSE) was performed by the physician on 1/24/17 at 11:30 AM. The following tests were performed: Complete Blood count (CBC), Urinalysis, Basic Metabolic Panel (BMP), Thyroid stimulating hormone, urine drug screen, Tylenol level, Salicylate level, alcohol level EKG (electrocardiogram) and chest x-ray.

Review of the Mental Health Consultation form dated 1/24/17 at 1:46 PM revealed, "... Client presented to ER (Emergency Room). c/o (complaints of) paranoid thoughts, poor sleeping habits... admitted to paranoid thoughts/ A-H (auditory hallucinations) "warning (him/her) lack of sleep and appetite. admitted to THC (tetrahydrocannabinol) used, and past alcohol abuse. Client agreed to voluntary placement..."

Hospital # 2 arranged for an appropriate transfer to Hospital # 3 on 1/24/17 at 5:50 PM.

Review of Hospital # 3's medical records revealed the patient was admitted on 1/24/17 at 8:16 PM with diagnosis of Psychosis.

Review of the Senior Behavioral Health Psychiatric Evaluation (Admission) dated 1/25/17 revealed the patient's chief complaint was psychosis. The physician documented, "... Per review of nursing notes on admission... Daughter reports that pt (patient) lives alone...has been politically fixated, since the election... behavior has escalated... has paper plates and papers with messages written on them taped to the floor and walls near the couch where... has been sleeping. Reportedly been stating "I'm connecting. I'm linking all of this. I've got connections." Reportedly paranoid about the government and making statements about the Nazi's and thinks the CIA (Central Intelligence Agency) is after (him/her)... Reportedly pt drove... to (Hospital # 1) " to get help" today... Reportedly while in the ED at that facility pt told nursing staff to handcuff (him/her) to the gurney, that voices were telling (he/she) might hurt somebody or hurt (self)...

It is somewhat unclear regarding the patient's psychiatric history. The patient is floridly psychotic (This term is used to mean that the psychosis is in full bloom, which is another way of saying that the afflicted's lost touch with our generally shared reality. www.quora.com)... has some elements of mania as well. Patient appears very grandiose paranoid simultaneously... has been responding to internal stimuli or actively hallucinating at times at home... disorganized in (his/her) thoughts and speech except... does say ... has been diagnosed with some mental condition and has seen multiple psychiatrists over the last 40 years... has been on medication in the past for... mental illness although he/she cannot remember any by name... the patient also reports that he/she is not feeling right and that he/she knows he/she is out of touch with reality. He/she is not currently prescribed any psychotic medications per review of his/her home medication list...

Mental Status Examination:
Mood: Anxious, elevated and irritable
Affect: Irritable, labile and expansive
Cognition: STM (short term memory) poor, concentration - moderately impaired...
Thought Process: ... Racing thoughts and pressured speech
Thought Content: Auditory hallucinations - present, Delusions - present, Ruminations and obsessions (Rumination means simply repetitively going over a thought or a problem without completion. www.psychologytoday.com)
Insight and Judgement: adequate...

Multi-axial diagnosis:
Axis I: Unspecified psychotic disorder, rule out schizophrenia, rule out bipolar type I disorder most recent episode manic with psychotic features, cannabis use disorder, alcohol use disorder (remission)...

Plan:
1. Admit (patient) to Hospital # 3 psychiatry...

Estimated length of stay: 14 days...

Review of Hospital # 3's Psychiatric Discharge Summary dated 2/2/17 revealed the following:

Discharge Summary:
Axis I: Unspecified psychotic disorder, cannabis use disorder, alcohol use disorder (remission)...

Reason for Admission: Psychosis...

Hospital Course:

... During this hospitalization patient was slowly titrated to an effective dose on Risperdal for active symptoms of psychosis... also started on Cogentin for EPS (extrapyramidal side effects) prophylaxis... started on low-dose Zoloft for symptoms of anxiety and titrated to an effective dose by the time of discharge... His/her very florid symptoms of psychosis seemed to respond rapidly to the antipsychotic medication. At no time did it ever seem that the patient suffered from a delirium or clear medical condition as a constricting factor of his/her psychosis. Note a cannabis-related psychotic disorder seemed unlikely. It is possible that the patient suffers from a primary psychosis such as schizophrenia or schizoaffective disorder, or a major mood disorder with psychotic features such as bipolar type I disorder... at the time of discharge patient's mood seemed stable... denied symptoms of depression... denied suicidal or homicidal ideations plans or intents... did not seem manic nor did (he/she) seem overtly psychotic...

Discharge Plan: Disposition: Assisted-living facility...

The patient's discharge medications included: Cogentin 1 mg (milligram) every day, Risperdal 4 mg every day and Zoloft 100 mg every day.

Interview conducted on 2/7/17 at 12:40 PM with Employee Identifier (EI) # 1, Emergency Department (ED) Physician (Hospital # 1) on duty during the day time on 1/23/17, when PI # 1 presented to the ED. EI # 1 verified he remembered PI # 1. He stated he was in with another patient and he heard yelling from triage and went to see the patient.

EI # 1 stated the patient was anxious and psychotic and this seemed new for the patient. He stated patient was agitated, had flight of ideas, but was alert. Neurological status was intact and the patient did not smell of alcohol. EI # 1 stated the patient's assessment was unremarkable. While in ED, the patient's urine drug screen was completed and tested positive cannabis. EI # 1 stated he thought the patient had gotten a hold of some "bad pot". The patient was anxious, yelling and was medicated with Geodon, which seemed to have calmed the patient down. He stated they contacted EI # 2, Mental Health Liaison/Psychological Counselor to come see the patient.

EI # 1 stated he talked with the patient about admission, but the patient refused and wanted to go home. The nurse explained to the patient about signing Against Medical Advice (AMA) and the patient said he/she wanted to leave. After Geodon was administered, the patient dramatically improved with no lingering effects from it. EI # 1 stated he had no concerns with him leaving AMA. He was stable.

EI # 1 stated that EI # 2 told him that she spoke with the patient and the patient had no history of mental illness and the GPU (Geripsych unit) doctor (EI # 4, Psychiatrist) was called. He stated he was told the psych doctor was not inclined to admit the patient to the GPU.

EI # 1 stated he knew the daughter was on her way to the hospital. He was not sure how she would feel about our decision to release him AMA, but the patient was stable. He stated when he left at 7:30 PM, the daughter was still not here.

Interview with EI # 3, Registered Nurse (RN) on 2/7/17 at 1:21 PM. EI # 3 was working in the ED on the day PI # 1 arrived.
EI # 3 stated when she saw the patient drive by in his/her car, the patient came into the hospital and wanted to talk to an RN. I talked with the patient who wanted to be hand cuffed to the chair because he/she felt like he/she would hurt him/herself or someone else. The patient then went through triage and was very cooperative with the assessment. The patient stated as long as he/she was talking to someone he/she felt okay. The patient asked me to call the police and I did because, he/she was so anxious. The police came to the hospital and sat with the patient. The patient was very anxious at that time, but cooperative.

EI # 3 stated the patient was restless and anxious. Lab personnel came and drew the labs without a problem. The patient was medicated with Geodon, he/she rested after that and said he/she felt better.

EI # 3 stated she called and spoke with the patient's daughter. EI # 3 stated the daughter she said that she lives in a town (approximately 3 hours away). The daughter said she felt like the patient watched too much news and that's the reason for the behavior.

EI # 3 stated EI # 1 wanted the patient to sign out Against Medical Advice (AMA), because the patient refused to be admitted. EI # 3 stated she told the on coming shift the patient signed out AMA, but was in the room waiting for his/her daughter to arrive. I thought maybe the daughter could get the patient to stay and be admitted to the hospital.

EI # 3 stated that EI # 2, Mental Health Liaison/Psychological Counselor came to see the patient for a mental health consult because the patient was saying he/she needed help, but would not say what kind of help he/she needed. EI # 3 stated when she left, the patient's daughter had not arrived at the hospital, so she did not get a chance to talk to her.

When questioned about the patient's condition at the end of her shift, she stated that the patient was very different from when he/she came in. The patient was calm after the Geodon and when the patient came into ED, he/she was very anxious and confused.

Interview with EI # 2, Mental Health Liaison/ Psychological Counselor on 2/7/17 at 1:52 PM.
EI # 2 verified she recalled PI # 1. She stated she received a call and went to the ED. The patient was in the ED admission waiting room. I got the patient registered. I then took the patient to trauma room # 2 and assisted to the bed. I asked the patient about his/her medications, but the patient could not remember, so the drug store was called. The patient was taking Theophylline, so a Theophylline level was drawn and it was fine. They also did a urine drug screen.

EI # 2 stated the patient told one of the RNs that he/she needed someone with him/her or he/she would hurt someone, so the police were called. EI # 2 stated she called the patient's daughter and described to her what was going on with the patient. The daughter said "... does not sound like him/her." The daughter requested us not send the patient anywhere until she arrived and she was 3 hours away.

EI # 2 stated she contacted EI # 4, Psychiatrist and he said he would not take the patient. "I am not taking him." EI # 2 stated she was not sure why he would not take the patient.

EI # 2 stated that after the patient calmed down and knew the patient's daughter was on her way, she left for the day. She stated that she told the ED staff to call her for placement. She stated she never received a call from the hospital.

When questioned about the difference in the patient from the time he/she came in until the time she left for the day, EI # 2 responded by saying the patient was manic when he/she first came to the ED, would not be still and would not listen. She said the patient's speech was rapid, confused and delusional. She stated by the time she left the patient was comfortable, laughing; had eaten and then took a nap.

When asked if she thought the patient could make a decision on his/her own for example to sign out AMA she said "... I don't know. I would not have left it up to him/her what to do because, it was all brand new. The daughter said to wait till she got there and that's what she wanted."

An interview was conducted on 2/8/17 at 8:30 AM with Employee Identifier (EI) # 5, RN. EI # 5 was working in the ED on the evening shift 1/23/17. EI # 5 denies remembering PI # 1, but did remember the patient's daughter. EI # 5 stated the patient's daughter was yelling at (EI # 5) and said she wanted the doctor to see the patient. EI # 5 stated she told EI # 6, ED Physician, who stated he would not get involved with it. EI # 5 stated she told the daughter that EI # 6 was not going to see the patient.

An interview was conducted on 2/8/17 at 8:50 AM with EI # 7, Licensed Practical Nurse who verified she remember the patient and that she briefly took care of the patient before the patient's daughter arrived. She stated the patient was in bed and calm at that time.

When questioned if she had spoken with the patient's daughter, EI # 7 stated "yes." EI # 7 stated she told the patient's daughter that the patient was discharged. She stated the patient's daughter became upset and said she wanted the patient to be re-evaluated. She stated that was when EI # 5 talked with EI # 6.

Interview conducted on 2/8/17 at 11:46 AM with Employee Identifier (EI) # 6, ED Physician assigned to the ED after 7:00 PM on 1/23/17, when PI # 1 was in the ED. EI # 6 verified he was assigned to the ED the night of 1/29/17. He stated he could not remember if he was asked to see the patient or asked to talk with the patient's daughter. EI # 6 verified he did not see the patient.

EI # 6 stated he had a patient in labor & delivery (L & D) at the time he was to report to the ED. EI # 6 stated that when he went to the ED, EI # 1, ED Physician (day shift) was still present and he was able to go back to L & D to deliver the patient's baby. He stated that while in L & D, EI # 8, Registered Nurse (RN) L & D (PI # 1's former sister in law) kept asking him if he had seen the patient. EI # 6 stated he told (EI # 8) that when he finished with delivery, he would go check the patient. He stated that when delivery was completed, he went back to the ED and the patient was already gone.


2. PI # 2 presented to the facility's ED with family on 6/29/16 at 12:54 PM with chief complaint of Hallucinations and "talking out of head."

Review of the Nursing Assessment documentation dated 6/29/16 revealed the following nursing documentation:

1:30 PM - "... Pt to ER (Emergency Room) triage done. Unable to obtain vital signs at this time due to hostile. Family in with patient. Holding (him/her) down and trying to talk (him/her) into staying in ER. Pt yelling and cussing at this time..."

1:50 PM - "... EI (EI) # 2, Mental Health Liaison/Psychological Counselor called... (Local) police called..."

2:05 PM - "... Geodon (20 mg) given IM... pt allowed vital signs to be obtained..."

Review of the Emergency Physician Record dated 6/29/16 revealed the physician performed the Medical Screening Exam (MSE) at 2:15 PM. The physician documented the chief complaint was acute psychosis, the patient was moderately to severely agitated with an onset of 3 days prior to presentation to the ED. The patient's history of illness in relation to onset, triggers, etc... were very poor and vague. Associated symptoms included frustration, agitation, hostility and confusion with questionable hallucinations. The patient's past medical history included acute psychosis on 2 occasions in the past 2 to 3 years.

The patient's physical examination indicated the patient was moderately to severely distressed, acutely psychotic, "somewhat" agitated and anxious. The patient's speech was rambling and disjointed.

Review of the Focus Notes dated 6/29/16 revealed the nurse documented the following:

4:30 PM - "... Transfer to Hospital # 4 in progress pending acceptance..."

5:30 PM - "... Pt (patient) up with family... unable to be transferred to Hospital # 4 d/t (due to) electrical problems... Pt to be transferred via ambulance to Hospital # 3 once room assignment given..."

6:15 PM - "... Pt accepted to Hospital # 3..."

6:45 PM - Geodon 20 mg (milligrams) IM (intramuscularly) given due to pt starting to get upset again..."

7:15 PM - "... Pt transferred via (as soon as possible) ASAP ambulance to Hospital # 3. No distress noted..."

Review of the Physician's Certification of Medical Necessity for Ambulance Transportation dated 6/29/16 revealed, "... Option 2: Ambulance Medically Necessary... Service/Equipment/Personnel not available... Psych..."

Review of the Transfer to Other Hospital Request/Refusal form dated 6/29/16 revealed no documentation of the reason for the patient to be transferred.

Review of PI # 2's medical record from Hospital # 3 revealed:

Admission History and Physical dated 6/30/16

... History of Present Illness: "... On interview today patient is lying down in (his/her) room... is very somnolent after receiving another Haldol, Benadryl, Ativan... since arriving here to the unit due to agitated behaviors... awakens briefly but... thought and speech are very disorganized... will make incoherent statements such as "all day and all night." Therefore I interviewed (spouse) for majority of (his/her) history... (Spouse) denies any known mental illness or family history of mental problems... reports acute onset of psychosis with a shot (patient) received for arthritis. Upon clarification ... most likely a corticosteroid injection... reports this was on 6/22... (patient's) thoughts mood and behaviors have worsened since that time developing into a psychotic mania most likely corticosteroid-induced although... may have an underlying bipolar disorder simply undiagnosed and be very susceptible... (patient) had a brain injury in motor vehicle accident in 1982 but without severe deficits... denies history of any recent falls or seizures... denies (patient) uses alcohol or drugs. Urine tox (toxicity) at outside hospital was negative for all substances including alcohol..."

"... Psychiatric History: (Spouse) denies any inpatient psychiatric hospitalizations, outpatient psychiatric care or history of suicide attempts..."

"Multiaxial Diagnosis: Axis I: unspecified psychotic disorder, rule out corticosteroid-induced psychosis/mania, rule out bipolar type I disorder manic with psychotic features, mild cognitive impairment due to traumatic brain injury...

Plan: 1. Admit (patient) to Hospital # 3's psychiatry...Estimated length of stay: 14 days..."

Review of the Discharge Summary dated 7/1/16 revealed the following:

"... Discharge Summary: Axis I. corticosteroid-induced psychotic disorder, mild cognitive impairment due to traumatic brain injury... Reason for admission: Acute disturbance of thought mood and behavior specifically aggression..."

"... During this hospitalization patient was thoroughly evaluated... past history and current symptoms were reviewed in detail... It appeared that the patient had received a corticosteroid injection for arthritis that was the precipitation of this psychosis/mania... (patient) had no prior history of any psychiatric illness nor any family history of mental problems... patient was started on Depakote for disturbance of mood as well as agitation prophylaxis... has history of traumatic brain injury and therefore is more susceptible to emotional disturbance as well as potentially seizures... tolerated this medication well... quickly stabilized on the ward and did not show any signs of aggression at the time of discharge... At the time of discharge (patient) was pleasant... not manic nor psychotic... denied suicidal homicidal or violent ideations plans or intent...An extensive safety review plan was discussed with patient and (spouse) who both verbalized an understanding..."

"Discharge Plan: Disposition: Home..."

Review of Hospital # 1's Final Census Report dated 6/29/16 revealed there were 5 inpatients in the Geriatric Psych Unit (GPU) with 3 potential male beds, including 301 B, 302 A and 302 B.

Review of Hospital # 1's Daily Time Report dated 6/29/16 revealed the following staff worked the GPU:
Day shift: (7 AM to 7 PM) - 3 Registered Nurses (RN), 1 RN (7:55 AM to 4:27 PM), 1 Mental Health Technician (MHT) (7 AM to 7 PM) and 1 MHT ( 6:18 AM to 2:26 PM)

Evening/Night shift: (7 PM to 7 AM) 2 RNs and 2 MHTs

An interview was conducted on 2/8/17 at 10:47 AM with Employee Identifier (EI) # 9, Registered Nurse (RN), who was present on 6/29/16 when PI # 2 presented to the Emergency Department (ED).

EI # 9 verified she remembered PI # 2. She stated the patient's family brought the patient in. The patient was getting upset, jumped off the exam table and lunged at her. She stated the police had to be called due to the patient's aggressive behavior. A police officer came and stayed with the patient for about 2 hours.

EI # 9 stated the patient had been at Hospital # 4 and we called them for transfer. They were told they were unable to admit the patient due to power outage and they assisted with getting the patient admitted to Hospital # 3.

When questioned if Hospital # 1's GPU had been called and asked to come to evaluate the patient for admission, she stated that she did not recall.

EI # 9 verified the nurse completes the Transfer form and the documented reason for transfer was "Service not available" at Hospital # 1. When questioned why services were not available in the GPU at Hospital # 1. She stated she was not sure.

Summary:
1. According to the (EI # 1) Emergency Department (ED) Physician's documentation on 1/23/17, PI # 1 presented to the hospital with anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations. Geodon was administered to the patient, which was effective in calming the patient. According to the physician, admission was discussed with the patient, who refused.

In interviews, it was determined the patient's daughter was contacted and was en route to the hospital. Once the patient's daughter arrived, she requested the patient be re-evaluated. According to the interview with EI # 5, Registered Nurse (RN) she informed EI # 6, ED Physician (assigned to ED after 7 pm) about the daughter's request for the patient to be re-evaluated, at which time EI # 6 refused. According to interviews, EI # 8, RN - Labor & Delivery (PI # 1's former sister in law) requested EI # 6, ED Physician to assess the patient. Once EI # 6 finished with the delivery of a patient's baby, EI # 6 returned to the ED and the patient had already left the facility.

The requests for the patient to be re-evaluated were not completed and PI # 1 failed to receive stabilizing treatment for acute psychiatric symptoms. PI # 1 presented to Hospital # 2 the following day (1/24/17) due to continued symptoms. The patient was medically screened and appropriately transferred to Hospital # 3's inpatient psychiatric unit for stabilizing treatment.

2. According to PI # 2's medical record documentation, the patient met admission criteria for the Ger

Based on review of facility policy, medical records and interviews, it was determined the facility failed to provide a medical screening examination (MSE) and stabilizing treatment for Patient Identifier (PI) # 1, a psychiatrically unstable patient who presented to the facility's Emergency Department (ED) on 1/23/17 at 2:49 PM. PI # 1 did not have a representative available until the patient's daughter arrived several hours later. PI # 1 signed an Against Medical Advice (AMA) form prior to the daughter's arrival. Once the patient's daughter arrived, she requested the patient to be re-evaluated by the physician, which was not completed. The patient left with the daughter.

PI # 1 presented to Hospital # 2's Emergency Department (ED) on 1/24/17, the following morning; was medically screened and appropriately transferred to a psychiatric unit at Hospital # 3. This delayed PI # 1's stabilizing treatment until admission to Hospital # 3 on 1/24/17 at 8:16 PM, which was 29 hours and 27 minutes after the patient initially presented to Grove Hill Memorial Hospital's ED.

This also affected Patient Identifier (PI) # 2, a patient who presented to the facility's ED on 6/29/16 with acute psychosis and hallucinations. The facility had the capacity and capability to treat PI # 2, but the patient was transferred to an inpatient psychiatric unit at Hospital # 3 on 6/29/16, thus delaying the patient's stabilizing treatment.

This affected 2 of 21 medical records reviewed.

Findings include:

Facility Policy

Subject: EMTALA (Emergency Medical Treatment and Labor Act) for Emergency Department Services

Policy: All patients presenting to Grove Hill Memorial Hospital's (Hospital # 1) Emergency, Labor and Delivery or Psychiatric Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.

In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.

All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic...

Medical Screening Exams:

Medical Screening Exams should include at a minimum the following:

... Vitals signs

History

Physical exam of affected systems and potentially affected systems

Exam of known chronic conditions

Necessary testing to rule out emergency medical conditions

Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary...

Complete documentation of the medical screening exam...

Emergency Medical Conditions:

An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:

Undiagnosed, acute pain...

Substance abuse symptoms, i.e., alcohol ingestion

Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, dis-associative state, inability to comprehend danger or care for self.

1. Patient Identifier (PI) # 1 presented to the Emergency Department (ED) on 1/23/17 at 2:49 PM with chief complaints of "possibly took too much meds (medications) - accidental."

Review of the Triage Assessment revealed the nurse documented the patient stated, "... feels like (he/she) is going to hurt (self) or someone else. Very cooperative..." Review of the nursing assessment revealed the patient was confused and anxious.

Review of the Emergency Physician Record dated 1/23/17 at 3:10 PM, the physician documented the patient's chief complaint of confusion earlier today. The physician documented the patient was alert and oriented times 4 (person, place, times and situation/recent events). The patient's social history was positive for THC (Tetrahydrocannabinol) and the physician documented questionable tainted marijuana.

The physician documented the patient's physical exam included the following signs/symptoms:
anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations.

Review of the medical record dated 1/23/17 revealed the following nursing documentation:

3:30 PM - the patient felt very anxious and that he/she may harm self or others.

3:35 PM - police were called to sit with patient and that he/she was cooperative at that time.

3:50 PM - Geodon 20 mg (milligrams) was administered IM (intramuscularly). (Geodon is an antipsychotic medication. Geodon (ziprasidone) administered intramuscular administration of single doses, peak serum concentrations typically occur at approximately 60 minutes post-dose or earlier and the mean half-life ranges from two to five hours. www.rxlist.com)

4:00 PM - sheriff's deputy was at the patient's beside and the patient was cooperative at that time.

5:30 PM - patient's daughter was called, made aware of the patient's status and the daughter was en route to the hospital from another town (several hours drive from the location of the hospital).

Review of the Emergency Physician Record dated 1/23/17 at 6:55 PM revealed the physician documented the patient was re-examined and the patient's condition was improved. The physician further documented having discussed with the patient admission to the hospital which the patient declined and "... will sign out AMA (against medical advice)..."

Review of the medical record dated 1/23/17 at 7:20 PM revealed the nurse documented the physician spoke with the patient about admission to the hospital, the patient declined admission at that time and signed out AMA.

Review of the Release of Grove Hill Memorial Hospital and Physicians of Responsibility Withdrawal of Request for Care dated 1/23/17 revealed the physician signed at 7:15 PM, and the patient and nurse signed at 7:20 PM.

Review of the Emergency Physician Record dated 1/23/17 revealed the physician documented the patient's disposition was marked "discharge" at 7:30 PM in an improved, stable condition.

Review of the late entry documentation dated 1/23/17 and signed on 2/7/17 by Employee Identifier (EI) # 2, Mental Health Liaison/Psychological Counselor revealed, "... Was called to ER (Emergency Room) lobby due to patient presenting with confusion... encountered (patient) sitting, slightly agitated and looking confused. (Patient) was asked to tell this writer what (he/she) needed and... responded, "I need help, why do you think I am here"... registered as ER patient and taken to Trauma room 2... (Patient) displayed rapid speech and confused thinking... Patient was very needy and wanted someone sitting in the room ... at all times. After labs came back... admitting psychiatrist was called to get placement on the GPU (Geri-psychiatric unit) at this hospital. The doctor refused to take patient for admission due to (patient) not having a history of mental illness... talked to patient's daughter... (daughter informed EI # 2) her aunt (EI # 8, Registered Nurse - Labor & Delivery) worked at our hospital... (EI # 8) was brought to patient bedside and patient calmed and talked to her but still with rapid speech. Patient daughter told nurse that she did not want patient sent anywhere until she arrived. I left and advised if daughter wanted patient placed I would come back to hospital and take care of this for them. Did not receive a call to return and was told the next morning that the patient signed... out AMA... This is a late entry as I thought I would be placing patient later the same night..."

Review of the medical record from Hospital # 2 revealed the patient presented to Hospital # 2's Emergency Department (ED) on 1/24/17 at 10:42 AM with chief complaint of paranoia and hallucinations, which were progressively worse over the last two weeks with no history of mental disorder.

Review of Hospital # 2's Emergency Nursing Record dated 1/24/17 at 10:42 AM revealed the nurse documented the patient had anxiety, sleeping difficulty, hostility, confusion and was having auditory and visual hallucinations.

Review of Hospital # 2's ED record revealed the medical screening examination (MSE) was performed by the physician on 1/24/17 at 11:30 AM. The following tests were performed: Complete Blood count (CBC), Urinalysis, Basic Metabolic Panel (BMP), Thyroid stimulating hormone, urine drug screen, Tylenol level, Salicylate level, alcohol level EKG (electrocardiogram) and chest x-ray.

Review of the Mental Health Consultation form dated 1/24/17 at 1:46 PM revealed, "... Client presented to ER (Emergency Room). c/o (complaints of) paranoid thoughts, poor sleeping habits... admitted to paranoid thoughts/ A-H (auditory hallucinations) "warning (him/her) lack of sleep and appetite. admitted to THC (tetrahydrocannabinol) used, and past alcohol abuse. Client agreed to voluntary placement..."

Hospital # 2 arranged for an appropriate transfer to Hospital # 3 on 1/24/17 at 5:50 PM.

Review of Hospital # 3's medical records revealed the patient was admitted on 1/24/17 at 8:16 PM with diagnosis of Psychosis.

Review of the Senior Behavioral Health Psychiatric Evaluation (Admission) dated 1/25/17 revealed the patient's chief complaint was psychosis. The physician documented, "... Per review of nursing notes on admission... Daughter reports that pt (patient) lives alone...has been politically fixated, since the election... behavior has escalated... has paper plates and papers with messages written on them taped to the floor and walls near the couch where... has been sleeping. Reportedly been stating "I'm connecting. I'm linking all of this. I've got connections." Reportedly paranoid about the government and making statements about the Nazi's and thinks the CIA (Central Intelligence Agency) is after (him/her)... Reportedly pt drove... to Grove Hill Hospital " to get help" today... Reportedly while in the ED at that facility pt told nursing staff to handcuff (him/her) to the gurney, that voices were telling (he/she) might hurt somebody or hurt (self)...

It is somewhat unclear regarding the patient's psychiatric history. The patient is floridly psychotic (This term is used to mean that the psychosis is in full bloom, which is another way of saying that the afflicted's lost touch with our generally shared reality. www.quora.com)... has some elements of mania as well. Patient appears very grandiose paranoid simultaneously... has been responding to internal stimuli or actively hallucinating at times at home... disorganized in (his/her) thoughts and speech except... does say ... has been diagnosed with some mental condition and has seen multiple psychiatrists over the last 40 years... has been on medication in the past for... mental illness although he/she cannot remember any by name... the patient also reports that he/she is not feeling right and that he/she knows he/she is out of touch with reality. He/she is not currently prescribed any psychotic medications per review of his/her home medication list...

Mental Status Examination:
Mood: Anxious, elevated and irritable
Affect: Irritable, labile and expansive
Cognition: STM (short term memory) poor, concentration - moderately impaired...
Thought Process: ... Racing thoughts and pressured speech
Thought Content: Auditory hallucinations - present, Delusions - present, Ruminations and obsessions (Rumination means simply repetitively going over a thought or a problem without completion. www.psychologytoday.com)
Insight and Judgement: adequate...

Multi-axial diagnosis:
Axis I: Unspecified psychotic disorder, rule out schizophrenia, rule out bipolar type I disorder most recent episode manic with psychotic features, cannabis use disorder, alcohol use disorder (remission)...

Plan:
1. Admit (patient) to Hospital # 3 psychiatry...

Estimated length of stay: 14 days...

Review of Hospital # 3's Psychiatric Discharge Summary dated 2/2/17 revealed the following:

Discharge Summary:
Axis I: Unspecified psychotic disorder, cannabis use disorder, alcohol use disorder (remission)...

Reason for Admission: Psychosis...

Hospital Course:

... During this hospitalization patient was slowly titrated to an effective dose on Risperdal for active symptoms of psychosis... also started on Cogentin for EPS (extrapyramidal side effects) prophylaxis... started on low-dose Zoloft for symptoms of anxiety and titrated to an effective dose by the time of discharge... His/her very florid symptoms of psychosis seemed to respond rapidly to the antipsychotic medication. At no time did it ever seem that the patient suffered from a delirium or clear medical condition as a constricting factor of his/her psychosis. Note a cannabis-related psychotic disorder seemed unlikely. It is possible that the patient suffers from a primary psychosis such as schizophrenia or schizoaffective disorder, or a major mood disorder with psychotic features such as bipolar type I disorder... at the time of discharge patient's mood seemed stable... denied symptoms of depression... denied suicidal or homicidal ideations plans or intents... did not seem manic nor did (he/she) seem overtly psychotic...

Discharge Plan: Disposition: Assisted-living facility...

The patient's discharge medications included: Cogentin 1 mg (milligram) every day, Risperdal 4 mg every day and Zoloft 100 mg every day.

Interview conducted on 2/7/17 at 12:40 PM with Employee Identifier (EI) # 1, Emergency Department (ED) Physician on duty during the day time on 1/23/17, when PI # 1 presented to the ED. EI # 1 verified he remembered PI # 1. He stated he was in with another patient and he heard yelling from triage and went to see the patient.

EI # 1 stated the patient was anxious and psychotic and this seemed new for the patient. He stated patient was agitated, had flight of ideas, but was alert. Neurological status was intact and the patient did not smell of alcohol. EI # 1 stated the patient's assessment was unremarkable. While in ED, the patient's urine drug screen was completed and tested positive cannabis. EI # 1 stated he thought the patient had gotten a hold of some "bad pot." The patient was anxious, yelling and was medicated with Geodon, which seemed to have calmed the patient down. He stated they contacted EI # 2, Mental Health Liaison/Psychological Counselor to come see the patient.

EI # 1 stated he talked with the patient about admission, but the patient refused and wanted to go home. EI # 1 stated the nurse explained to the patient about signing Against Medical Advice (AMA) and the patient said he/she wanted to leave. EI # 1 stated after Geodon was administered, the patient dramatically improved with no lingering effects from it. EI # 1 stated he had no concerns with him leaving AMA. He was stable.

EI # 1 stated that EI # 2 told him that she spoke with the patient and the patient had no history of mental illness and the GPU (Geripsych unit) doctor (EI # 4, Psychiatrist) was called. He stated he was told the psych doctor was not inclined to admit the patient to the GPU.

EI # 1 stated he knew the daughter was on her way to the hospital. He stated her was not sure how she would feel about our decision to release him AMA, but the patient was stable. He stated when he left at 7:30 PM, the daughter was still not at the facility.

Interview with EI # 3, Registered Nurse (RN) on 2/7/17 at 1:21 PM. EI # 3 was working in the ED on the day PI # 1 arrived. EI # 3 stated when she saw the patient drive by in his/her car, the patient came into the hospital and wanted to talk to an RN. I talked with the patient who wanted to be hand cuffed to the chair because he/she felt like he/she would hurt him/herself or someone else. The patient then went through triage and was very cooperative with the assessment. The patient stated as long as he/she was talking to someone he/she felt okay. The patient asked me to call the police and I did because, he/she was so anxious. The police came to the hospital and sat with the patient. The patient was very anxious at this time, but cooperative.

EI # 3 stated the patient was restless and anxious. Lab personnel came and drew the labs without a problem. The patient was medicated with Geodon, he/she rested after that and said he/she felt better.

EI # 3 stated she called and spoke with the patient's daughter. EI # 3 stated the daughter she said that she lives in a town (approximately 3 hours away). The daughter said she felt like the patient watched too much news and that's the reason for the behavior.

EI # 3 stated EI # 1 wanted the patient to sign out Against Medical Advice (AMA), because the patient refused to be admitted. EI # 3 stated she told on coming shift patient signed out AMA, but was in the room waiting for his/her daughter to arrive. I thought maybe the daughter could get the patient to stay and be admitted to the hospital.

EI # 3 stated that EI # 2, Mental Health Liaison/Psychological Counselor came to see the patient for a mental health consult because the patient was saying he/she needed help, but would not say what kind of help he/she needed. EI # 3 stated when she left, the patient's daughter had not arrived at the hospital, so she did not get a chance to talk to her.

When questioned about the patient's condition at the end of her shift, she stated that the patient was very different from when he/she came in. The patient was calm after the Geodon and when the patient came into ED, he/she was very anxious and confused.

Interview with EI # 2, Mental Health Liaison/ Psychological Counselor on 2/7/17 at 1:52 PM.
EI # 2 verified she recalled PI # 1. She stated she received a call and went to the ED. The patient was in the ED admission waiting room. I got the patient registered. I then took the patient to trauma room # 2 and assisted to the bed. I asked the patient about his/her medications, but the patient could not remember, so the drug store was called. The patient was taking Theophylline, so a Theophylline level was drawn and it was fine. They also did a urine drug screen.

EI # 2 stated the patient told one of the RNs that he/she needed someone with him/her or he/she would hurt someone, so the police were called. EI # 2 stated she called the patient's daughter and described to her what was going on with the patient. The daughter said "... does not sound like him/her." The daughter requested us not send the patient anywhere until she arrived and she was 3 hours away.

EI # 2 stated she contacted EI # 4, Psychiatrist and he said he would not take the patient. "I am not taking him." EI # 2 stated she was not sure why he would not take the patient.

EI # 2 stated that after the patient calmed down and knew the patient's daughter was on her way, she left for the day. She stated that she told the ED staff to call her for placement. She stated she never received a call from the hospital.

When questioned about the difference in the patient from the time he/she came in until the time she left for the day, EI # 2 responded by saying the patient was manic when he/she first came to the ED, would not be still and would not listen. She said the patient's speech was rapid, confused and delusional. She stated by the time she left the patient was comfortable, laughing; had eaten and then took a nap.

When asked if she thought the patient could make a decision on his/her own for example to sign out AMA she said "... I don't know. I would not have left it up to him/her what to do because, it was all brand new. The daughter said to wait till she got there and that's what she wanted."

An interview was conducted on 2/8/17 at 8:30 AM with Employee Identifier (EI) # 5, RN. EI # 5 was working in the ED on the evening shift 1/23/17. EI # 5 denies remembering PI # 1, but did remember the patient's daughter. EI # 5 stated the patient's daughter was yelling at (EI # 5) and said she wanted the doctor to see the patient. EI # 5 stated she told EI # 6, ED Physician, who stated he would not get involved with it. EI # 5 stated she told the daughter that EI # 6 was not going to see the patient.

An interview was conducted on 2/8/17 at 8:50 AM with EI # 7, Licensed Practical Nurse, who verified she remember the patient and that she briefly took care of the patient before the patient's daughter arrived. She stated the patient was in bed and calm at that time.

When questioned if she had spoken with the patient's daughter, EI # 7 stated "yes." EI # 7 stated she told the patient's daughter that the patient was discharged. She stated the patient's daughter became upset and said she wanted the patient to be re-evaluated. She stated that was when EI # 5 talked with EI # 6.

Interview conducted on 2/8/17 at 11:46 AM with Employee Identifier (EI) # 6, ED Physician assigned to the ED after 7:00 PM on 1/23/17, when PI # 1 was in the ED. EI # 6 verified he was assigned to the ED the night of 1/29/17. He stated he could not remember if he was asked to see the patient or asked to talk with the patient's daughter. EI # 6 verified he did not see the patient.

EI # 6 stated he had a patient in labor & delivery (L & D) at the time he was to report to the ED. EI # 6 stated that when he went to the ED, EI # 1, ED Physician (day shift) was still present and he was able to go back to L & D to deliver the patient's baby. He stated that while in L & D, EI # 8, Registered Nurse (RN) L & D (PI # 1's former sister in law) kept asking him if he had seen the patient. EI # 6 stated he told (EI # 8) that when he finished with delivery, he would go check the patient. He stated that when delivery was completed, he went back to the ED and the patient was already gone.

Summary: According to the (EI # 1) ED Physician's documentation on 1/23/17, PI # 1 presented to the hospital with anxious/psychotic, moderate distress, paranoid, agitated, rambling thought content, disorganized/flight of ideas, poor insight, questionable suicidal/homicidal ideation/plan, grandiosity and visual/auditory hallucinations. Geodon was administered to the patient, which was effective in calming the patient. According to the physician, admission was discussed with the patient, who refused.

The patient's daughter was contacted and was en route to the hospital. Once the patient's daughter arrived, she requested the patient be re-evaluated. According to the interview with EI # 5, Registered Nurse informed EI # 6, ED Physician (assigned to ED after 7 pm) about the daughter's request for the patient to be re-evaluated, at which time EI # 6 refused. According to interviews, the patient's ex-sister in law requested EI # 6, ED Physician to assess the patient. Once EI # 6 finished with the delivery of a patient's baby, EI # 6 returned to the ED and the patient had already left the facility.

The request for the patient to be re-evaluated were not completed. The patient presented to Hospital # 2 on the following day due to continued symptoms and was medically screened and appropriately transferred to Hospital # 3's inpatient psychiatric unit.

2. PI # 2 presented to the facility's ED with family on 6/29/16 at 12:54 PM with chief complaint of Hallucinations and "talking out of head."

Review of the Nursing Assessment documentation dated 6/29/16 revealed the following nursing documentation:

1:30 PM - "... Pt to ER (Emergency Room) triage done. Unable to obtain vital signs at this time due to hostile. Family in with patient. Holding (him/her) down and trying to talk (him/her) into staying in ER. Pt yelling and cussing at this time..."

1:50 PM - "... EI (EI) # 2, Mental Health Liaison/Psychological Counselor called... (Local) police called..."

2:05 PM - "... Geodon (20 mg) given IM... pt allowed vital signs to be obtained..."

Review of the Emergency Physician Record dated 6/29/16 revealed the physician performed the Medical Screening Exam (MSE) at 2:15 PM. The physician documented the chief complaint was acute psychosis, the patient was moderately to severely agitated with an onset of 3 days prior to presentation to the ED. The patient's history of illness in relation to onset, triggers, etc... were very poor and vague. Associated symptoms included frustration, agitation, hostility and confusion with questionable hallucinations. The patient's past medical history included acute psychosis on 2 occasions in the past 2 to 3 years.

The patient's physical examination indicated the patient was moderately to severely distressed, acutely psychotic, "somewhat" agitated and anxious. The patient's speech was rambling and disjointed.

Review of the Focus Notes dated 6/29/16 revealed the nurse documented the following:

4:30 PM - "... Transfer to Hospital # 4 in progress pending acceptance..."

5:30 PM - "... Pt (patient) up with family... unable to be transferred to Hospital # 4 d/t (due to) electrical problems... Pt to be transferred via ambulance to Hospital # 3 once room assignment given..."

6:15 PM - "... Pt accepted to Hospital # 3..."

6:45 PM - Geodon 20 mg (milligrams) IM (intramuscularly) given due to pt starting to get upset again..."

7:15 PM - "... Pt transferred via ASAP (as soon as possible) ambulance to Hospital # 3. No distress noted..."

Review of PI # 2's medical record from Hospital # 3 revealed:

Admission History and Physical dated 6/30/16

... History of Present Illness: "... On interview today patient is lying down in (his/her) room... is very somnolent after receiving another Haldol, Benadryl, Ativan... since arriving here to the unit due to agitated behaviors... awakens briefly but... thought and speech are very disorganized... will make incoherent statements such as "all day and all night." Therefore I interviewed (spouse) for majority of (his/her) history... (Spouse) denies any known mental illness or family history of mental problems... reports acute onset of psychosis with a shot (patient) received for arthritis. Upon clarification ... most likely a corticosteroid injection... reports this was on 6/22... (patient's) thoughts mood and behaviors have worsened since that time developing into a psychotic mania most likely corticosteroid-induced although... may have an underlying bipolar disorder simply undiagnosed and be very susceptible... (patient) had a brain injury in motor vehicle accident in 1982 but without severe deficits... denies history of any recent falls or seizures... denies (patient) uses alcohol or drugs. Urine tox (toxicity) at outside hospital was negative for all substances including alcohol..."

"... Psychiatric History: (Spouse) denies any inpatient psychiatric hospitalizations, outpatient psychiatric care or history of suicide attempts..."

"Multiaxial Diagnosis: Axis I: unspecified psychotic disorder, rule out corticosteroid-induced psychosis/mania, rule out bipolar type I disorder manic with psychotic features, mild cognitive impairment due to traumatic brain injury...

Plan: 1. Admit (patient) to Hospital # 3's psychiatry...Estimated length of stay: 14 days..."

Review of the Discharge Summary dated 7/1/16 revealed the following:

"... Discharge Summary: Axis I. corticosteroid-induced psychotic disorder, mild cognitive impairment due to traumatic brain injury... Reason for admission: Acute disturbance of thought mood and behavior specifically aggression..."

"... During this hospitalization patient was thoroughly evaluated... past history and current symptoms were reviewed in detail... It appeared that the patient had received a corticosteroid injection for arthritis that was the precipitation of this psychosis/mania... (patient) had no prior history of any psychiatric illness nor any family history of mental problems... patient was started on Depakote for disturbance of mood as well as agitation prophylaxis... has history of traumatic brain injury and therefore is more susceptible to emotional disturbance as well as potentially seizures... tolerated this medication well... quickly stabilized on the ward and did not show any signs of aggression at the time of discharge... At the time of discharge (patient) was pleasant... not manic nor psychotic... denied suicidal homicidal or violent ideations plans or intent...An extensive safety review plan was discussed with patient and (spouse) who both verbalized an understanding..."

"Discharge Plan: Disposition: Home..."

An interview was conducted on 2/8/17 at 10:47 AM with Employee Identifier (EI) # 9, Registered Nurse (RN), who was present on 6/29/16 when PI # 2 presented to the Emergency Department (ED).

EI # 9 verified she remembered PI # 2. She stated the patient's family brought the patient in. The patient was getting upset, jumped off the exam table and lunged at her. She stated the police had to be called due to the patient's aggressive behavior. A police officer came and stayed with the patient for about 2 hours.

EI # 9 stated the patient had been at Hospital # 4 and we called them for transfer. They were told they were unable to admit the patient due to power outage and they assisted with getting the patient admitted to Hospital # 3.

When questioned if Hospital # 1's GPU had been called and asked to come to evaluate the patient for admission, she stated that she did not recall.

EI # 9 verified the nurse completes the Transfer form and the documented reason for transfer was "Service not available" at Grove Hill Memorial Hospital. When questioned why services were not available in the GPU at Grove Hill Memorial Hospital. She stated she was not sure.

Summary:
According to PI # 2's medical record documentation, the patient met admission criteria for the Geriatric Psych Unit (GPU); in that, the patient was 55 years of age and was displaying psychotic behavior. There was no documentation the ED physician or the ED staff attempted to contact the GPU or psychiatrist for potential admission of PI # 2 on 6/29/16. The patient was transferred to Hospital # 3, thus delaying the patient's stabilizing treatment.

Based on review of facility policies, medical records, Hospital # 1's Final Census Reports, Hospital # 1's Daily Time Reports and interviews, it was determined the facility failed to provide stabilizing treatment for 1 of 21 records reviewed.

This affected Patient Identifier (PI) # 2, a patient who presented to the facility's ED on 6/29/16 with acute psychosis and hallucinations. The facility had the capacity and capability to treat PI # 2, but the patient was transferred to an inpatient psychiatric unit at Hospital # 3 on 6/29/16.

Findings include:

Facility Policy

Subject: EMTALA (Emergency Medical Treatment and Labor Act) for Emergency Department Services

Policy: All patients presenting to Grove Hill Memorial Hospital's (Hospital # 1) Emergency, Labor and Delivery or Psychiatric Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.

In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment...

Grove Hill Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA...

Grove Hill Memorial Hospital may not transfer patients who are potentially unstable as long as the hospital had the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity.

If a patient is to be transferred for medical necessity the following guidelines must be followed:

A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or

The patient requests a transfer in writing...

... Emergency medical conditions include:

... Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, dis-associative state, inability to comprehend danger or care for self.

Facility Policy:
Southern Oaks Grove Hill Memorial Hospital
Policy/Procedure # 1-01
Subject: Program Narrative

I. Purpose/Goals:

... D. To include provisions for the major diagnostic, medical psychiatric and psychosocial treatment modalities found in a comprehensive psychiatric inpatient program.

E. To provide a stable, therapeutic environment and a structured, supportive treatment program for diagnosis and treatment of acute psychiatric symptoms or decompensating clinical conditions that severely impair daily functioning...

II. Criteria for Admission:

A. The patient must be 55 years of age or older unless the individual has similar age-related issues.

B. The patient must have a provisional DSM V (Diagnostic and Statistical Manual of Mental Disorders) Axis I psychotic diagnosis.

C. The patient must be medically stable...

... E. The patient must meet one or more of the following criteria to establish medical necessity for inpatient psychiatric care:

... 4. Is suffering from an acute onset or exacerbation of psychotic symptoms (hallucinations, delusions, disorganized thinking)...

1. PI # 2 presented to the facility's ED with family on 6/29/16 at 12:54 PM with chief complaint of Hallucinations and "talking out of head."

Review of the Nursing Assessment documentation dated 6/29/16 revealed the following nursing documentation:

1:30 PM - "... Pt to ER (Emergency Room) triage done. Unable to obtain vital signs at this time due to hostile. Family in with patient. Holding (him/her) down and trying to talk (him/her) into staying in ER. Pt yelling and cussing at this time..."

1:50 PM - "... EI (EI) # 2, Mental Health Liaison/Psychological Counselor called... (Local) police called..."

2:05 PM - "... Geodon (20 mg) given IM... pt allowed vital signs to be obtained..."

Review of the Emergency Physician Record dated 6/29/16 revealed the physician performed the Medical Screening Exam (MSE) at 2:15 PM. The physician documented the chief complaint was acute psychosis, the patient was moderately to severely agitated with an onset of 3 days prior to presentation to the ED. The patient's history of illness in relation to onset, triggers, etc... were very poor and vague. Associated symptoms included frustration, agitation, hostility and confusion with questionable hallucinations. The patient's past medical history included acute psychosis on 2 occasions in the past 2 to 3 years.

The patient's physical examination indicated the patient was moderately to severely distressed, acutely psychotic, "somewhat" agitated and anxious. The patient's speech was rambling and disjointed.

Review of the Focus Notes dated 6/29/16 revealed the nurse documented the following:

4:30 PM - "... Transfer to Hospital # 4 in progress pending acceptance..."

5:30 PM - "... Pt (patient) up with family... unable to be transferred to Hospital # 4 d/t (due to) electrical problems... Pt to be transferred via ambulance to Hospital # 3 once room assignment given..."

6:15 PM - "... Pt accepted to Hospital # 3..."

6:45 PM - Geodon 20 mg (milligrams) IM (intramuscularly) given due to pt starting to get upset again..."

7:15 PM - "... Pt transferred via ASAP (as soon as possible) ambulance to Hospital # 3. No distress noted..."

Review of the Physician's Certification of Medical Necessity for Ambulance Transportation dated 6/29/16 revealed, "... Option 2: Ambulance Medically Necessary... Service/Equipment/Personnel not available... Psych..."

Review of the Transfer to Other Hospital Request/Refusal form dated 6/29/16 revealed no documentation of the reason for the patient to be transferred.

Review of PI # 2's medical record from Hospital # 3 revealed:

Admission History and Physical dated 6/30/16

... History of Present Illness: "... On interview today patient is lying down in (his/her) room... is very somnolent after receiving another Haldol, Benadryl, Ativan... since arriving here to the unit due to agitated behaviors... awakens briefly but... thought and speech are very disorganized... will make incoherent statements such as "all day and all night." Therefore I interviewed (spouse) for majority of (his/her) history... (Spouse) denies any known mental illness or family history of mental problems... reports acute onset of psychosis with a shot (patient) received for arthritis. Upon clarification ... most likely a corticosteroid injection... reports this was on 6/22... (patient's) thoughts mood and behaviors have worsened since that time developing into a psychotic mania most likely corticosteroid-induced although... may have an underlying bipolar disorder simply undiagnosed and be very susceptible... (patient) had a brain injury in motor vehicle accident in 1982 but without severe deficits... denies history of any recent falls or seizures... denies (patient) uses alcohol or drugs. Urine tox (toxicity) at outside hospital was negative for all substances including alcohol..."

"... Psychiatric History: (Spouse) denies any inpatient psychiatric hospitalizations, outpatient psychiatric care or history of suicide attempts..."

"Multiaxial Diagnosis: Axis I: unspecified psychotic disorder, rule out corticosteroid-induced psychosis/mania, rule out bipolar type I disorder manic with psychotic features, mild cognitive impairment due to traumatic brain injury...

Plan: 1. Admit (patient) to Hospital # 3's psychiatry...Estimated length of stay: 14 days..."

Review of the Discharge Summary dated 7/1/16 revealed the following:

"... Discharge Summary: Axis I. corticosteroid-induced psychotic disorder, mild cognitive impairment due to traumatic brain injury... Reason for admission: Acute disturbance of thought mood and behavior specifically aggression..."

"... During this hospitalization patient was thoroughly evaluated... past history and current symptoms were reviewed in detail... It appeared that the patient had received a corticosteroid injection for arthritis that was the precipitation of this psychosis/mania... (patient) had no prior history of any psychiatric illness nor any family history of mental problems... patient was started on Depakote for disturbance of mood as well as agitation prophylaxis... has history of traumatic brain injury and therefore is more susceptible to emotional disturbance as well as potentially seizures... tolerated this medication well... quickly stabilized on the ward and did not show any signs of aggression at the time of discharge... At the time of discharge (patient) was pleasant... not manic nor psychotic... denied suicidal homicidal or violent ideations plans or intent...An extensive safety review plan was discussed with patient and (spouse) who both verbalized an understanding..."

"Discharge Plan: Disposition: Home..."

Review of Hospital # 1's Final Census Report dated 6/29/16 revealed there were 5 inpatients in the Geriatric Psych Unit (GPU) with 3 potential male beds, including 301 B, 302 A and 302 B.

Review of Hospital # 1's Daily Time Report dated 6/29/16 revealed the following staff worked the GPU:
Day shift: (7 AM to 7 PM) - 3 Registered Nurses (RN), 1 RN (7:55 AM to 4:27 PM), 1 Mental Health Technician (MHT) (7 AM to 7 PM) and 1 MHT ( 6:18 AM to 2:26 PM)

Evening/Night shift: (7 PM to 7 AM) 2 RNs and 2 MHTs

An interview was conducted on 2/8/17 at 10:47 AM with Employee Identifier (EI) # 9, Registered Nurse (RN), who was present on 6/29/16 when PI # 2 presented to the Emergency Department (ED).

EI # 9 verified she remembered PI # 2. She stated the patient's family brought the patient in. The patient was getting upset, jumped off the exam table and lunged at her. She stated the police had to be called due to the patient's aggressive behavior. A police officer came and stayed with the patient for about 2 hours.

EI # 9 stated the patient had been at Hospital # 4 and we called them for transfer. They were told they were unable to admit the patient due to power outage and they assisted with getting the patient admitted to Hospital # 3.

When questioned if Hospital # 1's GPU had been called and asked to come to evaluate the patient for admission, she stated that she did not recall.

EI # 9 verified the nurse completes the Transfer form and the documented reason for transfer was "Service not available" at Grove Hill Memorial Hospital. When questioned why services were not available in the GPU at Grove Hill Memorial Hospital. She stated she was not sure.

Summary:
According to PI # 2's medical record documentation, the patient met admission criteria for the Geriatric Psych Unit (GPU); in that, the patient was 55 years of age and was displaying psychotic behavior. There was no documentation the ED physician or the ED staff attempted to contact the GPU for potential admission of PI # 2 on 6/29/16. There was no documentation the patient/caregiver requested for the patient to be transferred to Hospital # 3.

According to the Final Census Report and Daily Time Report, the facility had capacity and capability to treat PI # 2, instead transferred the patient to Hospital # 3.