HospitalInspections.org

Based on policy review, medical record review, observation and interview, nursing services failed to ensure a patient's right to involve a family member or patient representative in decisions about care was not violated for 3 of 3 (Patient #1, 2, and 3) sampled patients transferred to a psychiatric facility under involuntary admission. Nursing services also failed to ensure a patient's personal valuables/belongings were appropriately stored and disposed for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy, "Patient Rights," revealed, " ...POLICY ...To ensure that each patient, or when appropriate the patient's representative, is informed of the patient's Rights and Responsibilities in advance of furnishing or discontinuing patient care whenever possible ...Your Rights and Responsibilities as a Patient ...You have the right to be involved in all aspects of your care, including the right to ...Involve a family member or patient representative in decisions about your care ...Be given information about your discharge plan and any ongoing care you may need after you leave the hospital ..."

Review of the hospital policy, "EMTALA [Emergency Medical Treatment and Labor Act]" revealed, " ...Transfer ...In all transfer circumstances, the patient's signature should be obtained on the 'EMTALA Authorization for Transfer' Form ..."

Review of the hospital policy, "Discharge Planning/Continuum of Care," revealed, " ...PURPOSE ...To ensure patients are informed of their options and have free choice in the selection of post-discharge providers and services ...DEFINITION ...Discharge planning and care coordination are hospital services, which assists patients and their families in making post-hospital treatment arrangements for ongoing care ...Discharge planning and care coordination for each patient may be initiated during pre-admission planning upon admission, or at any stage of the hospitalization ...Collaboration between the community, the facility and the professional disciplines provides the healthcare link which safeguards the patient and those involved in assisting with discharge planning by facilitating the process of informed decision making by the patient or the patient's responsible party ..."

2. Medical record review revealed Patient #1 was a 37-year-old female who presented to the Hospital Emergency Department (ED) on 8/2/2021 at 3:25 AM via Emergency Medical Services (EMS). Registered Nurse (RN) #1 documented Patient #1 was yelling, screaming, cursing, and was very manic upon arrival to the Emergency Department (ED).

ED Physician #1 initially saw Patient #1 on 8/2/2021 at 3:27 AM. ED Physician #1 documented EMS reported they were called by Patient #1's son who reported Patient #1 had not been acting right in the past several days. The son reported Patient #1 started pretending she was someone else and started talking with a fake accent. The son reported her behavior had become more bizarre with increased yelling and screaming, and she had become hyper religious in the previous couple of days. The family was unable to control her, and the son called EMS. ED Physician #1 documented EMS reported Patient #1's husband would not allow EMS to enter the house and threatened them about coming into the house. Patient #1 came out of the house with a knife and a bottle of water in her hands. EMS reported Patient #1 poured water over her head and feet and stated she had been baptized. EMS reported Patient #1 talked about seeing unicorns during her transport to the hospital. EMS reported the son stated Patient #1 had a previous admission to a psychiatric facility.

ED Physician #1 documented Patient #1 had a past medical history of pancreatic adenocarcinoma (cancer) and was being treated by oncology (received first round of chemotherapy on 7/14/2021) at Hospital #2. ED Physician #1 ordered a computed tomography (CT) of the head which ruled out any metastatic disease of the brain. A urine drug screen was positive for oxycodone (narcotic) and cannabis (psychoactive drug). Patient #1 had a low potassium level of 2.9 millimoles/liter (normal range between 3.5 and 5.2 millimoles/liter). Patient #1 was given 40 milliequivalents potassium by mouth, and her potassium level increased to 4.5 millimoles/liter.

RN #1 documented on 8/2/2021 at 4:16 AM that Patient #1's social history included, " ...Home/Environment ...Lives with Children, Spouse. Marital Status of Patient if Patient Independent Adult: Married ..."

Patient was seen by Mobile Crisis (mental health service for emergency mental health evaluations), and Patient #1 was scheduled for transfer to a psychiatric facility for involuntary admission. ED Physician #2 documented on 8/3/2021 at 6:48 AM that Patient #1's boyfriend called and stated her psychiatrist and oncologist were aware Patient #1 was in the hospital, and the family was attempting to get her transferred to Hospital #2.

ED Physician #3 documented on 8/4/2021 at 8/4/2021 at 6:59 PM that Hospital #2 declined Patient #1 as a transfer patient.

ED Physician #4 documented on 8/4/2021 at 10:17 PM that Hospital #3 had accepted Patient #1 and that Patient #1 would be transported to Hospital #3 in Memphis, TN.

The "EMTALA AUTHORIZATION FOR TRANSFER" form dated 8/4/2021 revealed Patient #1 was transferred to Hospital #3 for psychiatry services with a diagnosis of Acute Psychosis. There was no signature in the blank entitled, "Signature of Patient or Responsible Party."

Patient #1 was transferred to Hospital #3 on 8/5/2021 at 12:02 AM.

The face sheet listed Patient #1's spouse as the emergency contact (telephone number listed) and Patient #1's mother as the next of kin (telephone number listed). There was no documentation the hospital notified the responsible party or family of the transfer or attempted to include them in Patient #1's discharge planning process. There was no documentation the ED staff determined it was not safe or it was inappropriate to communicate with the responsible party or family.

3. Medical record review revealed Patient #2 was a 43-year-old female who presented to the Hospital ED on 8/7/2021 at 8:40 PM for evaluation of anxiety and hallucinations, and Patient #2 reported she had been abused by her husband.

ED Physician #3 initially saw Patient #2 on 8/7/2021 at 8:59 PM. ED Physician #3 documented Patient #2 reported she has not been able to leave her house since she got married sometime in February or March 2021(exact date unknown), because her husband had locked her in the house. Patient #2 reported her husband beats her but did not want to involve police. Patient #2 reported she used to take Seroquel (antipsychotic) prescribed by a mental health facility, but she was unsure why the medication was prescribed.

RN #2 documented on 8/8/2021 that Patient #2's husband called the ED several times inquiring about Patient #2. RN #2 documented Patient #2's husband became angry when he was informed that patient did not want the hospital to share any information with him. RN #2 documented Patient #2's sister was at bedside, and they were talking about an order of protection for the patient.

Patient #2 was seen and evaluated by Mobile Crisis, and Patient #2 was scheduled for transfer to a psychiatric facility for involuntary admission.

The "EMTALA AUTHORIZATION FOR TRANSFER" form dated 8/11/2021 revealed Patient #2 was transferred to Hospital #4 for psychiatry services with a diagnosis of Psychosis. There was no signature in the blank entitled, "Signature of Patient or Responsible Party."

Patient #2 was transferred to Hospital #4 on 8/11/2021 at 6:20 PM.

The face sheet listed Patient #2's sister as the emergency contact (telephone number not listed) and Patient #2's mother as the next of kin (telephone number listed). There was no documentation the hospital notified the responsible party or family of the transfer or attempted to include them in Patient #2's discharge planning process. There was no documentation the ED staff determined it was not safe or it was inappropriate to communicate with the responsible party or family.

4. Medical record review revealed Patient #3 was a 35-year-old male who was brought to the Hospital ED on 8/14/2021 at 5:54 PM by his father who reported Patient #3 had disorganized thoughts and unable to keep up with his home medications since he was taken off of his Zyprexa (antipsychotic) medication. The father reported Patient #3 had medication changes within the past week with Zyprexa stopped 5 days ago and a new medication (Patient #3 and father were unaware of the name of the new medication) started 2 days ago.

Patient #3 was seen and evaluated by Mobile Crisis, and Patient #3 was scheduled for transfer to a psychiatric facility for involuntary admission.

The "EMTALA AUTHORIZATION FOR TRANSFER" form dated 8/15/2021 revealed Patient #3 was transferred to Hospital #5 for psychiatry services with a diagnosis of Schizophrenic Disorders. There was no signature in the blank entitled, "Signature of Patient or Responsible Party."

Patient #3 was transferred to Hospital #5 on 8/15/2021 at 7:16 AM.

The face sheet listed Patient #3's niece as the emergency contact (telephone number not listed) and Patient #3's father as the next of kin (telephone number listed). There was no documentation the hospital notified the responsible party or family of the transfer or attempted to include them in Patient #3's discharge planning process. There was no documentation the ED staff determined it was not safe or it was inappropriate to communicate with the responsible party or family.

5. In an interview on 10/25/2021 at 10:34 AM, the ED Nursing Director stated it was the nursing staff's responsibility to contact the responsible party or family to inform them about the patient and any discharge planning when it was safe and appropriate.

In an interview on 10/25/2021 at 12:33 PM, the Chief Nursing Officer (CNO) stated that many patients with psychiatric concerns show up at the ED with no family or have family to include in the discharge planning process. The CNO confirmed the responsible party or family should be included in the discharge planning process when it was safe and appropriate for the patient, and it should be documented in the medical record.

6. Review of the hospital policy, "Patient Valuables," revealed, " ...POLICY ...Guidelines to insure the proper care and security of valuables received from patients admitted and/or treated at [Hospital #1] ...INPATIENT PROCEDURE ...Upon admission patients are encouraged to give any personal items not needed and/or valuables (money, wallets, jewelry, credit cards, cell phones) to their families or significant other for safekeeping ...In the event no one is available to keep the valuables, the patient is informed that a safe is available. The items may be kept in the safe until discharge and/or upon request from the patient or documented designee ..."

Review of the hospital policy, "Guidelines for Care of Behavioral Health Patients in the Emergency Department," revealed, " ...All personal items removed from the patient should be inventoried, documented and the disposition of said items documented in the patient record ..."

7. Medical record review revealed Patient #1 was a 37-year-old female who presented to the Hospital Emergency Department (ED) on 8/2/2021 at 3:25 AM via Emergency Medical Services (EMS). Registered Nurse (RN) #1 documented Patient #1 was yelling, screaming, cursing, and was very manic upon arrival to the ED.

RN #1 documented on 8/2/2021 at 6:11 AM the following valuables/belongings for Patient #1: 1 bathrobe, 1 pair of pants, 1 shirt, 1 undergarment, 1 bracelet, 1 ring, and 1 purse. RN #1 documented the valuables were labeled, but there was no documentation where the valuables/belongings were stored.

After examination, Patient #1 was scheduled for transfer to a psychiatric facility for involuntary admission.

Patient #1 was transferred to Hospital #3 on 8/5/2021 at 12:02 AM.

There was no documentation of the disposition of Patient #1's valuables/belongings upon discharge from the Hospital ED.

8. Observations made on 10/25/2021 at 11:47 AM revealed there were 3 lockers inside the dirty linen room located across the hall from a set of double doors leading to the ED. All three lockers were open and empty of any patient valuables/belongings.

9. In an interview on 10/25/2021 at 10:34 AM, the ED Nursing Director stated patient valuables/belongings would be bagged in an envelope, labeled with the patient's sticker, and placed in the lockers located outside the ED. The ED Nursing Director stated there were only 3 lockers used by the ED staff to store patient valuables/belongings. The ED Nursing Director stated the staff would lock the patient valuables/belongings in the locker until the patient left the ED. The ED Nursing Director stated the patient valuables/belongings would be sent with the patient when transferred to another facility. The ED Nursing Director stated nursing staff should document the final disposition of the patient valuables/belongings in the medical record. The ED Nursing Director confirmed there was no documentation of the final disposition of Patient #1's valuables/belongings in the medical record.

In an interview on 10/25/2021 at 11:00 AM, the Chief Nursing Officer (CNO) stated patient valuables/belongings would be inventoried, labeled, and placed in a locker when the patient arrived in the ED. The CNO stated the patient valuables/belongings would be sent with the patient if the patient was transported, and the valuables/belongings would be given to the transport personnel. The CNO stated nursing staff should document the disposition of the patient valuables/belongings.