HospitalInspections.org

Based on records reviewed and interviews, for 11 (Patients #1, #3, #6, #17, #20, #22, #23, #31, #32, #33 & #46) of 46 sampled Emergency Department (ED) patient records, the Hospital failed to ensure qualified medical personnel (mental health vendor clinicians) performed an appropriate Medical Screening Examination (MSE) in accordance with Hospital Bylaws to determine whether or not an Emergency Medical Condition (EMC) existed.

Findings included:

The document titled Bylaws of the Medical Staff, dated 5/14/15, indicated the definition of Allied Health Professions as medical professionals licensed by the Commonwealth of Massachusetts (excluding Physicians, Dentists and Podiatrists), including nurse practitioners, clinical nurse specialist, clinical nurse midwives, licensed independent clinical social workers, physiologists, physician assistants, certified registered nurse anesthetists, acupuncturists and other disciplines added at the discretion of the Medical Executive Committee and the Governing Board.

The document titled Allied Health Credentialing Procedures, Section 11 of the Hospital Credentialing Manual, dated 2013, indicated that the Hospital Board permits members of the Allied Health Staff to provide patient care services and currently only Licensed Psychologists and Licensed Independent Clinical Social Workers are credentialed to provide services independently as permitted by the Hospital and in keeping with all applicable rules, policies and procedures.

The document titled Emergency Services Program (ESP-a contracted service) Specifications, undated, indicated that ESP clinicians (mental health vendor clinicians) provided crisis assessment, intervention, and stabilization services to emergency psychiatric patients in the ED.

The Hospital policy titled Emergency Department Patient Transfers, dated 7/2014, indicated that an ED Provider performed the Medical Screening Examination. The ED Patient Transfers policy did not indicate a definition for "Provider" that identified the type of provider qualified to perform a Medical Screening Examination to determine whether or not an Emergency Medical Condition existed according to the Medical Staff Bylaws.

The Surveyor interviewed the Senior Director of Risk Management & Patient Safety at 11:15 A.M. on 7/14/16. The Risk Manager said that it was unknown if ESP staff were licensed because the Hospital did not credential them.

Medical Records for eleven ED patients indicated that nine different mental health vendor clinicians provided the mental health evaluations for the patients presenting to the ED with an acute mental health crisis. There was no documentation to indicate that the contracted mental health vendor clinicians were credentialed and granted privileges by the Hospital's Governing Body and Hospital Bylaws.

The Surveyor interviewed the Chief of Psychiatry at 9:40 A.M. on 7/15/16. The Chief of Psychiatry said that the mental health clinicians that provided mental health evaluations for patients that presented to the ED with an acute mental health crisis were not credentialed through the Hospital Medical Staff.

The Medical Record for Patient #31, dated 4/24/16 at 12:00 A.M. indicated the Patient was seen by an ESP clinician for a mental health crisis. There was no documentation that the ESP clinician was credentialed by the Hospital.

The Medical Record for Patient #31, dated 4/24/16 at 1:30 A.M., indicated that the Patient was seen by a Forensic Psychologist. There was no documentation that the Forensic Psychologist was credentialed by the Hospital.

The Surveyor interviewed the Senior Director of Risk Management & Patient Safety at 10:45 A.M. on 7/27/16. The Senior Director of Risk Management & Patient Safety said the Forensic Psychologist was not credentialed by the Hospital.

Based on records reviewed and interviews, for 1 (Patients #31) of 46 sampled Emergency Department (ED) patient records, the Hospital failed to ensure an appropriate transfer.

Findings included:

The Hospital policy titled Emergency Department Patient Transfers, dated 7/2014, indicated the Hospital used the Authorization for Transfer Form for documentation of all out of Hospital patient transfers. The policy indicated that the transferring physician confirmed that the receiving facility agreed to the transfer.

The ED Medical Record for Patient #31, visit #1, dated 4/24/16 at 12:00 A.M. and written by an ED physician, indicated that the Emergency Services Provider (ESP) Clinician as well as a Forensic Psychologist evaluated Patient #31 and the plan was for transfer to a forensic psychiatric hospital (for a psychiatric emergency medical condition). The ED Medical Record did not contain an Emergency Department Patient Transfers Form (a physician signed certification summary of the risks and benefits of transfer) and did not indicate the name of the physician accepting the transfer.

A Hospital Report, dated 4/24/16, indicated police returned Patient #31 to the ED at the request of the accepting physician. The Report indicated a nurse supervisor accepted the patient transfer and a physician at the forensic psychiatric hospital did not accept Patient #31. The Report indicated that the physician at the forensic psychiatric hospital wanted Patient #31 to return to the ED to have an ECG.

The ED Medical Record for Patient #31, visit #2, dated 4/24/17 at 7:05 A.M., indicated that the ED Physician was contacted by the physician at the forensic psychiatric hospital who expressed concern that Patient #31 did not have an electrocardiogram (ECG) performed in the ED. The ED Medical Record indicated Police were contacted and returned Patient #31 to the ED for re-evaluation and an ECG.

The Surveyor interviewed the the Senior Director of Risk Management & Patient Safety at 9:00 A.M. on 7/15/16. The Senior Director of Risk Management & Patient Safety said that the Hospital did not investigate this event as a potential Emergency Medical Treatment and Labor Act (EMTALA) violation.