HospitalInspections.org

1. Based on observations, medical record reviews, hospital policy and procedure review, Emergency Medical Services(EMS) report reviews, Medical Staff Rules and Regulations review, job description review, and staff interviews, the hospital failed to ensure that appropriate medical screening examinations were provided within the capability of the hospital's Emergency Department (ED), to include the ancillary services (Psychiatric Services) of Qualified Medical Personnel routinely available in the Emergency Department to determine whether or not an emergency psychiatric condition existed for 3 (Patient #2, #17, and #24) of 25 medical records reviewed. Additionally, the hospital's Medical Staff Rules and Regulations failed to state that Licensed Clinical Social Workers were determined qualified to conduct psychiatric screening examinations. Review of 2(Patient #9 and #21) of 25 patient medical records revealed the patients failed to receive a appropriate medical screening examination after presenting to the hospital's emergency department with identified medical issues. Cross Refer to findings in Tag A-2406.

2. Based on medical record review, policy and procedure review, EMS Run Reports review, bed census reports review, and ED Medical Director and staff interviews, the hospital's Emergency Department failed to ensure an individual determined to have an emergency psychiatric condition was provided within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition for 4 (Patient #24, #16, #2, and #17) of 25 patient records reviewed, who presented to the hospital's emergency department with suicidal and homicidal ideation. Cross Refer to findings in Tag A 2407.

3. Based on the review of patient medical records, EMS Run Report review, policy and procedure review, bed census report review, and interviews, the hospital failed to provide further medical evaluation and treatment required based on the individual's source of payment, and the hospital failed to admit 1 (Patient #3) of 25 sampled patient records reviewed due to lack of insurance. Cross Refer to findings in Tag A-2408.

4 Based on medical record reviews, policy and procedure review, EMS run report review, and bed census reports review, the hospital inappropriately transferred individuals when they failed to provide medical treatment within its capacity that minimized the risk to the individual's health for 4 (Patient #2, #3, #9 and #24) of 25 medical records reviewed . The hospital had the capacity to treat these individuals and this resulted in inappropriate transfers. Cross Refer to findings in Tag A-2409.

5. Based on patient medical record reviews, taped conversation review, Referral Center Log review, Emergency Medical Treatment And Labor ACT (EMTALA) policies and procedures review, Urology Physicians meeting, bed census report review, on-call schedule review, and interviews, Greenville Memorial Hospital (Hospital #1) refused to accept individual(s) from a referring hospital based on an orally communicated community call plan, which resulted in inappropriate transfers of individuals who required such specialized capabilities (Urology) and facilities as the hospital had the capacity to treat 2 (two) of twenty-five (25) patients who required emergent urological services. (Patient #11 and #12). Cross Refer to findings in Tag A-2411.

Based on observations, medical record reviews, review of the Emergency Department policies and procedures, review of the hospital's Emergency Medical Services Report, review of the hospital's Medical Staff Rules and Regulations, Job description review, and staff interviews, the hospital failed to ensure that an appropriate Medical Screening Examinations(MSE) were provided within the capability of the hospital's Emergency Department(ED), to also include the ancillary services (Psychiatric Services) by Qualified Medical Personnel(QMP) routinely available in the Emergency Department to determine whether or not an emergency psychiatric condition existed for 3 patients (Patient #2, #17, and #24) of 25 patient medical records reviewed where the patient presented with a psychiatric diagnosis. Additionally, the hospital's Medical Staff Rules and Regulations failed to state that Licensed Clinical Social Workers(LCSW) were determined qualified to conduct psychiatric screening examinations for patients in the Emergency department. Review of 2(Patient #9 and #21) of 25 patient medical records revealed the patients failed to receive a appropriate medical screening examination after presenting to the hospital's emergency department with identified medical issues.

The findings are:

ED Patient #2 (No Psychiatric MSE)
Patient #2 presented to Hospital #1's Emergency Department on 4/30/2019 at 13:11 PM via car with grandparents.

Triage Nurse Notes 4/30/2019 at 1:14 PM
"Per grandmother, 'He has been exposed to a tremendous amount of abuse. We have had custody since September 7th. He has aggression and physical violence towards others. He choked his brother this morning until he passed out.' Pt denies SI/HI(Suicidal Ideation/Homicidal Ideation) at this time. Pt(Patient) calm and cooperative in triage. Call in note: 8 yo(year old) Male, increasing violent behavior. Has molested his cousin x(times) 3 in the last week - has been reported. Tried to strangle his brother. Patient's brother was killed by Mother's boyfriend. DSS(Department of Social Services) involved. Maternal Grandparents have custody. Coming from internal medicine via POV (Private Owned Vehicle)."
Chief Complaint: Aggressive Behavior; Homicidal

ED Physician Provider Note dated 4/30/2019 at 1:33 PM
"The patient is a 8 y.o. generally healthy male who presents to the ED for aggressive behavior. He currently lives with his grandparents. His grandparents report he currently has been exhibiting increasingly violent behavior. He will spontaneously hit his siblings and cousins. He has also taken rocks and thrown at his siblings and cousins. .....His grandparents learned that he has been molesting his 4 y/o female cousin for at least a week. The molestation was reported to the police and social services this morning. He has a history of anti- social personality, ADHD (Attention Deficit Hyperactivity Disorder- a mental health disorder, combination of persistent problems), and dissociative disorder. He also has a history of PTSD (Post Traumatic Stress Disorder) due in part to witnessing his younger brother's abuse and murder. A consult with the ED's psychiatric social worker was placed at 1:54 PM.

LMSW Evaluation ED 4/30/2019 at 5:31 PM
"Involuntary Hold (Emergency Hold-is a brief involuntary detention of a person presumed to have Mental Illness) Start 4/30/2019 at 13:45 PM and Expiring 4/30/2019 at 1:35 PM. Chief Complaint Aggressive Behavior/ Homicidal. Pt(Patient) is a 8 y.o. male presented to ED after choking his brother almost to the point of passing out. Patient's risk for homicide is rated severe since pt presented to ED after choking brother. Per pt's grandparents, pt is aggressive and impulsive."
Plan: "SW(Social Worker) collaborated with ED MD and ED Psychiatrist. PT placed on WP(White paper). SW to assist with inpatient psychiatric placement." Patient #2 was never evaluated by a psychiatrist. The hospital failed to ensure that Patient #2 received a psychiatric assessment/evaluation by Qualified Medical Personnel.


ED Patient #17
On 1/29/2020 at 09:50 AM, Patient #17's chart was reviewed with Registered Nurse (RN) #6 who verified the findings related to the documentation in the patient's chart.

EMS(Emergency Medical Services)
On 1/29/2020 at 10:15 AM, review of Patient #17 ED chart revealed the patient presented to the hospital's ED on 1/28/2020 at 3:24 PM via EMS for "Psychiatric Evaluation "and auditory hallucinations.

Triage Encounter Notes 1/28/2020 3:26 PM
On 1/29/2020 at 10:30 AM, review of the nurse triage notes revealed "Arrives via EMS with c/o (complaint /of) auditory hallucinations, hx (history) of PTSD (Post Traumatic Stress Disorder), pt was running around outside with a knife, denies SI/HI(Suicidal Ideation/Homicidal Ideation), positive ETOH (Alcohol). There was no documentation of a triage level assigned to the patient.

Physician Orders
Review of physician orders dated 6:55 PM on 1/28/2020 revealed the patient was ordered observation with sitters at bedside for "at risk for violence - psychosis", and an ED consult to Psych Social Worker on 1/28/2020 at 3:49 PM.

Medical Screening Examination by ED Physician on 1/28/2020 at 3:38 PM
Review of the Medical Screening Examination revealed "..... is a 30 y.o. male with a past medical history of PTSD who presents emergency department for psychiatric evaluation. Patient was brought in by EMS(Emergency Medical Services) earlier today after patient was seen running around outside with a knife. Patient states that he has been "wigging out" for approximately 1 week. Patient reports that he is in the Special Forces for the United States and United Nations who is on a special mission for spiritual warfare. Patient states that he was running around with a knife today because he was summoning spiritual beings to destroy them. He states he would not hurt any humans. He had no intent on harming himself or others. Patient also states that he has been experiencing auditory hallucinations in the form of a speaker that has been implanted in his right ear that connects to a satellite. Patient states that the general of the United States talks to him through that speaker. Patient states that he does drink alcohol daily, and he has drunk one half of a pint of liquor today. .....he denies any associated SI or HI." Review of the section, labeled, Review of System, revealed, "Psychiatric Behavior: Positive for behavioral problems, confusion and hallucinations." Review of the section labeled, Physical Exam, revealed, "Psychiatric: He has a normal mood and affect. His speech is normal. He is actively hallucination. Thought content is delusional. Thought content is not paranoid. He expresses no homicidal and no suicidal ideation. "
Differential Diagnosis: includes but is not limited to new onset Schizophrenia, Bipolar, Depression, Hypoglycemia, other electrolyte abnormalities, other infectious etiologies....Patient was transferred over to behavioral health (located in the hospital's emergency department), and will further receive treatment there. Review of the hospital's census for its 65 bed inpatient psychiatric unit showed the census on 1/28/2020 was 31, and the bed census was 33 on 1/29/2020.

Licensed Medical Social Worker (LMSW) Screening
There was a psychiatric screening conducted by LMSW #2 on 1/28/2020 at 6:41 PM. Review of the LMSW's progress notes revealed "PLAN-SW (Social Worker) reviewed with ED MD &(and) (psychiatrist). Pt. has been placed on ITC and will need to be reassessed later. "The patient's insurance was listed as self-pay. The facility failed to ensure that Patient #17 received a psychiatric assessment by Qualified Medical Personnel.

Psychiatric Screening Examination
There was no documentation of a psychiatrist consult in the patient's chart to assess the patient for the existence of an emergency psychiatric condition or the need for further treatment. The hospital failed to ensure that Patient #17 received a psychiatric evaluation by Qualified Medical Personnel and stabilizing treatment. There was no documentation of the patient's disposition.


Patient #9
Review of Patient #9's chart on 1/29/2020 at 1:00 PM revealed the patient presented to Hospital #2's Emergency Department(ED) on 12/27/2019 at 07:44 AM by ambulance from an area nursing home where the patient was receiving rehabilitation therapy after a recent hospitalization for Pneumonia. Review of the patient's chart received from Hospital #1 revealed the patient has a history of end-stage renal disease and was due for a dialysis treatment this morning, had shortness of breath all night, and this morning began to complain of acute severe chest pain. Documentation in the chart showed the patient was in severe distress and diaphoretic. Based on the patient's symptoms, the patient was transported emergently to Hospital #1."

Triage
Review of the triage nurse notes dated 12/27/2019 at 07:50 AM revealed the patient received an Electrocardiogram 12 lead, vital signs were documented as: Temperature 98.3 F (Fahrenheit), Heart Rate 115!, Blood Pressure 183/141!, and SpO2(amount of oxygen in the blood) 100%(percent) with 4 liters oxygen via nasal cannula. The patient was assigned an ESI (Emergency Severity Index) acuity level of 2 (scale with 1 requiring the most intense services and 5 requiring the least intense services), placed on cardiac monitoring, and a oximeter to measure the patient's oxygen saturation level.

ED Physician History and Physical
ED Physicians History and Physical dated 12/27/2019 at 09:46 AM revealed, "This is a petite and frail appearing Hispanic female in severe distress. This patient is ashen in color and diaphoretic. Auscultation reveals a Tachycardia regular rate and rhythm. There is a 3/6 systolic ejection murmur on the left sternal border. Respirations are moderately to severely labored. Auscultation reveals rales about halfway up in both lung fields. Management options: at this time, the patient is noted to be severely Hypertensive. Patient started on high-dose Nitroglycerin drip to bring blood pressure down. I have asked the unit coordinator to confirm that our Nephrologist is in town as the patient will require emergent dialysis in the ICU(Intensive Care Unit). Patient will be given IV(Intravenous) morphine along with high dose nitroglycerin and the patient has already received aspirin prior to arrival."
"8:30 AM: the patient has been re-examined. The patient is still having significant respiratory distress. My ultrasound exam as well as chest x-ray confirmed significant pulmonary Edema and the patient also has history of scleraderma and restrictive lung disease. Therefore, believe the patient could benefit from BiPAP which is being ordered at this time. 9:30 AM: the patient's work up returns with lab studies is documented: Initial Troponin is 0.06. Sodium is 127 and Creatnine is 2.4. With initial Troponin elevation, I will re-contact the physician to see if he still endorses the patient staying here for treatment. The patient is symptomatically improved on nitroglycerin drip and chest x-ray shows increased infiltrated process suggestive of a pulmonary edema or pneumonia and the patient also has known connective tissue long disease. 9:45 AM: I spoke with the physician at 9:31 AM and he felt the patient continue to stay for treatment and our hospital despite an initial Troponin of 0.06. He feels that this does not represent STMI(An ST-segment elevation myocardial infarction. A serious form of heart attack in which a coronary artery is completely blocked and a large part of the heart muscle is unable to receive blood), and that the patient does not require acute intervention. Patient is symptomatically approved[sic] at this time. I have confirmed that the Nephrologist is in town and available. I will now contact the hospitalist to request admission. 10:45 AM: I contacted the hospitalist for admission of this patient. He informed me that he had just spoken with a Nephrologist and he was en route to Arizona to attend the football playoff game. Despite numerous calls to the Nephrologist office reassuring me that he was available, I have contacted him directly, and he informed me that he is out of town, and the patient will have to be transferred. I will now inform the patient's family of this change and contact the referral center to attempt transfer. 11:46 AM:. The ICU Intensive Care Unit) hospitalist service has contacted me, and I have discussed the case at length with him. He agrees to except[sic] this patient and transfer to there. As soon as we are notified of the patient's bed number, she will be transferred by EMS.






39463

ED Patient #24
Observations
On 1/27/2020 at 11:45 AM, observations during a tour with the Emergency Department(ED) Medical Director (Adult) in the Emergency Department's C Pod (Bed C 46) revealed a male patient lying on the bed. The ED Medical Director stated the patient was admitted 45 minutes ago with a chief complaint of "Aggressive Behavior". Observations showed a police officer stationed in the hall outside of the patient's room. Bed C 46 had a television and a telemetry unit with long loose cords and a metal intravenous pole at the head of the bed.

Chart Review with Registered Nurse (RN) #5
On 01/30/2020 at 9:55 AM, in the conference room, Patient #24's chart was reviewed with Registered Nurse #5 who verified the findings. RN# 5 verified the patient was admitted to the hospital's ED on 1/28/2020 at 11:07 AM with Aggressive Behavior. On 1/28/2020 at 1:03 PM, when the surveyor requested the patient's psychiatric physician consult and the psychiatric screening examination, RN #5 stated, "There is no psychiatric screening consult."

Triage Notes
On 1/30/2020 at 11:03 AM, review of Patient #24's chart revealed the patient presented to Hospital 1's Emergency Department via ambulance transport with a chief complaint of "Aggressive Behavior" on 1/28/2020 at 11:07 AM. Review of the nurse triage note dated 1/28/2020 at 11:08 AM revealed,"Pt (Patient) autistic. states he was grounded which made him mad. grabbed a sliding bracket out of his dresser drawer and hit 2 staff members and bit another staff member. Pt has some abrasions on his knee, arms, and head from the altercation. denies SI (Suicidal Ideation). comes from a group home special needs." The triage nurse assigned an ESI (Emergency Severity Index) Level 2 (Emergent) to the patient. On an ESI scale of level 1 to level 5, level 1 is defined as the most serious level and level 5 is defined as the least serious level.

ED Nurse Intake Assessment
Review of the ED nurse's intake assessment dated 1/28/2020 at 12:03 PM was significant related to the documentation of the patient's "Suicide Risk Evaluation" that revealed the patient was at risk for suicide with a history of previous suicidal attempts/behaviors. The nurse documented "pt (patient) has a hx (history) of cutting himself. He denies cutting today. when pt(patient) asked if he was suicidal, he states not now." In the section of the nurse encounter form, labeled, "Risk Factors for imminent Suicidal Behaviors:, the nurse documented, "Sudden changes in emotional state; Parasuicidal (an apparent attempt at suicide, commonly called suicidal gestures) behaviors within the last year; Suicidal/parasuicidal thoughts, threats, planning; Recent discharge from mental health facility." The ED nurse documented the patient's risk for suicide was "mild" with a rational documented as "Pt is well known to ED. Pt. has hx of getting angry and cutting himself or threatening to harm himself." Review of the section on the nurse encounter notes, labeled, "Homicide Risk Evaluation and Protective Factors", the nurse documented the patient was a risk to harm others related to a history of violence or threats toward others. The ED nurse documented, "pt. became upset because of some restrictions placed on him in the group home. He hit another resident in the group home and bit one of the caregivers." The ED nurse documented the patient's risk for homicide was mild, and for "Assaultive Behavior?, "yes" was documented in the section of the nurse encounter notes, labeled, "Risk Assessment". Documentation revealed the patient was ordered observation status every 15 minutes for suicidal/homicidal/violent patient with a hospital sitter at bedside.

ED Physician Notes
On 1/30/2020, review of Patient #24's chart revealed the ED Physician's assessment was initiated on 1/28/2020 at 11:30 AM. The ED physician documented the patient's chief complaint was "Aggressive Behavior". The ED Physician documented, ".....21 -year old male presents emerged[sic] department after complaints of aggressive behavior and statements of self injury. Patient reports that he got mad this morning and did not think his actions through well and then he became frustrated so he attacked that people at his group home. Patient is in custody and the accompanying police officer reports that the patient became very aggressive at the group home and used a slide from a drawer to attack the other people at the home and then tried to cut his own wrist. Please[sic] also reports the patient said something along the lines of "I want to end the pain before I hurt somebody else." In the section of the physician progress note, labeled, "Skin:", the ED physician documented,"Comments: On the patient's forearm, right side, there is a 0.5 inch laceration that is superficial. There are several others which are much longer but are old. Patient also has very superficial abrasions to his face and neck." Review of the ED physician's orders at 11:30 AM revealed "ED Consult to Psych Social Work", and "Please irrigate with normal saline the laceration to the patient's right wrist." In the section of the progress notes, labeled, "Medical Decision Making", the ED physician documented "21 - year- old male presents emerged[sic] department with after complaints of aggressive behavior. He has been assessed by psychiatry. Patient will be discharged. Condition: Stable Disposition: Discharge". There was no documentation that a psychiatrist performed a psychiatric screening examination for Patient #24.

Licensed Medical Social Worker (LMSW #2) Notes
Review of the Licensed Medical Social Worker (LMSW #2) assessment for Patient #24 dated 1/28/2020 at 1:03 PM revealed the patient's chief complaint was "Aggressive Behavior". Review of the LMSW #2's progress notes revealed "Problems/ Somatic Symptoms: ..... Pt(Patient) presents to ED in police custody due to hitting one of the residents at his group home with a metal slide that came of a drawer. He also hit and bit one of his caregivers. Per pt., he became angry because of some new restrictions in the home. He denies cutting himself with the metal slide from the drawer, but officer at bedside indicates pt cut himself today. Pt. denies SI (Suicidal Ideation). Pt. does admit to hurting the resident and caregiver at the group home. He states it happened so fast, he was not able to use his coping skills. He is denying HI (Homicidal Ideation) or wanting to harm others at this time. Behavior Changes: (self injurious behavior), Insomnia: no problems reported or observed." LMSW #2 documented, "No problems reported or observed for Appetite, Anxiety, Depression Symptoms, Mania Symptoms, Hallucinations, or Delusions". In the section of the progress notes, labeled, "Mental Status", LMSW #2 documented "During interview Patient Appears: (uncooperative at times. "I don't want to go into that."). In the section of the progress notes, labeled, "Suicide Risk Evaluation and Protective Factors", LMSW #2 documented, "Is Patient at Risk for Suicide? "Yes"; "Suicide Risk Evaluation: History of previous suicidal attempts/behaviors"; "Suicide Risk Comments: pt has a hx(history) of cutting himself. He denies cutting today. when pt asked if he was suicidal, he states, "not now"; Access to Firearms: Yes, sw(social worker) contacted .....(manager at group home); In the section of the progress note, labeled, "Risk factors for Imminent Suicidal behaviors:", LMSW #2 documented, "Sudden changes in emotional state, Parasuicidal behaviors within last year, Suicidal/parasuicidal thoughts, threats, planning, Recent discharge from Mental Health facility; Patient's Risk for Suicide is Judged to be: Mild"; Rational for above Decision: Pt is well known to ED. Pt. has hx of getting angry and cutting himself or threatening to harm himself." LMSW #2 documented in the section of the progress note, labeled, "Homicide Risk Evaluation and Protective Factors", "at risk to harm others, has a history of violence or threats toward others, pt. became upset because of some restrictions placed on him in the group home. he hit another resident in group home and bit one of the caregivers." In the section labeled, "Homicidal Protective Factors", LMSW #2 documented "Variety of clinical interventions and support, Community support, Restricted access to highly lethal means of suicide", and patient "Risk for Homicide is judged to be: "Mild". In the section labeled, "Abuse Risk Assessment:", LMSW #2 documented "Assault Behavior: Yes". LMSW #2 documented in the section of the progress notes, labeled "Clinical Impression: Autism Spectrum Disorder". LMSW #2 documented, "Plan: sw(social worker) reviewed with ED MD(Medical Doctor) and psychiatrist. Pt does meet criteria for inpatient psychiatric treatment. sw notified (manager at group home), pt would be discharged with police officer at bedside." Patient #24 was discharged on 01/28/2020 at 2:19 PM with a police officer. There was no documentation that Patient #24 received a psychiatric screening examination from a psychiatrist while in the hospital's ED.

Governance Rules and Regulations
Review of the hospital's governance "Rules and Regulations" had no approval for the hospital's LMSWs as a Qualified Medical Person(QMP) to perform psychiatric medical screening examinations. Review of the bed census dated 1/28/2020 for the 65 bed psychiatric inpatient unit showed a census of 39 inpatients. The hospital had the capability and capacity to admit Patient #24 on 1/28/2020.

Interview with ED Medical Director - Adults
On 1/30/2020 at 1:30 PM, an interview was conducted with the Medical Director for the Adult Emergency Department in the conference room. When the ED Director was asked if Patient #24 received an MSE (Medical Screening Examination" by a psychiatrist, the ED Medical Director reported, "He did not have a psych consult. He left in police custody. Police can treat his condition." When the ED Medical Director was asked if it was common for patients to go to the police station for treatment, the ED Medical Director responded, "Yes, we do that all of the time. They can give treatment there because they have a doctor and a nurse there." Further review of the patient's medical record on 1/30/2020 at 3:00 PM revealed there were no instructions to the police officer accompanying the patient related to suicide precautions or homicide precautions after the patient's discharge from the ED.

Interview with Licensed Medical Social Worker (LMSW)#2
On 1/30/2020 at 12:25 PM, a telephone interview was conducted with LMSW #2 in the conference room. LMSW #2 verified he/she was consulted to do a psychiatric assessment for Patient #24. LMSW #2 verified the patient's assessment determined the patient was at risk for suicide and at risk to harm others. LMSW #2 stated, "I told the physician who ordered the social work psychiatric consult, and the psychiatrist on duty in the ED on 1/28/2020 of my findings, but the physician reported the patient did not meet criteria for inpatient treatment." LMSW #2 verified that he/she does not conduct a medical screening examination for psychiatric patients. LMSW #2 reported that he/she uses the hospital's screening form to obtain information from the patient, and then informs the emergency department physicians and psychiatric physicians of the data collected from the patient. The hospital failed to ensure that a psychiatric assessment was provided for Patient #24 on 1/28/2020 by Qualified Medical Personnel.



ED Patient #21
Observations
On 1/29/2020 at 11:15 AM, observations during a tour of the hospital's Emergency Department (ED) of Pod C revealed 6 patients with sitters providing 1:1 close observation for each patient. Observations revealed a male patient in Pod C 046. The Registered Nurse (RN) revealed the patient was a "Case Management Patient" brought to the hospital by Emergency Medical Services (EMS) and the police. A brief record review on 1/29/2020 at the Pod C nurse station with the RN revealed the patient was admitted to the ED on 1/28/2020 with a chief complaint of "Bad Living Conditions". On 1/29/2020 and 1/30/2020, review of the patient's chart revealed the patient had an elevated Creatnine level: 1.69 (Normal 0.72 - 1.25 mg/dl (milligrams/deciliters) treated with Lactated Ringers intravenous fluids and the patient required skilled level physical and occupational therapy due to recent cerebral vascular accident and general debility. The patient was boarded in the hospital's emergency room from 1/28/2020 to 1/30/2020 and had not been discharged when the survey team exited the hospital. There was no evidence of a medical screening examination or history and physical completed for the patient.

Triage
On 1/29/2020 at 3:00 PM, review of Patient 21's electronic medical record (EMR) in the conference room with RN #5 revealed Patient #21 was admitted to the hospital's ED on 1/28/2020 at 2:39 PM accompanied by police escort after Meals on Wheels reported bad living conditions in the patient's home. Review of the nurse's triage note dated 1/28/2020 at 2:39 PM revealed ".....call out per police after Meals on Wheels expressed concern for the patient's living conditions, DSS (Department of Social Services) involved at this time, hstry(history) of stroke 1 year ago. The patient was triaged as ESI(Emergency Severity #3 on the ESI index scale where ESI level #1 requires the most resources and ESI level #5 requires the least resources.

Physician Encounter Notes
On 1/28/2020 at 6:20 PM, ED Physician #9 documented in an ED Update note that the patient's elevated Creatnine 1.65 (Normal 0.72- 1.25 mg/dl(milligrams/deciliters) requires Lactated Ringers intravenous fluids, recheck Creatnine in the AM, orders for Physical Therapy and Occupational Therapy consults, Tuberculosis skin test for placement, and Licensed Medical Social Worker(LMSW) psychiatric consult ordered on 1/28/2020. There was no medical screening examination on the patient's chart. The ED physician also ordered a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP). At 3:20 PM on 1/29/2020, RN #5 reviewed all of the physician progress notes and verified he/she could not find a medical screening examination, and stated "I believe the physicians have 24 hours to write the note." There was no ED physician progress note dated 1/29/2020. On 1/29/2020 at 3:15 PM, RN #5 reported ED Physician #10 was supposed to see the patient today although more than 24 hours had passed since the patient's admission. On 1/29/2020 at 3:20 PM, documentation of the patient's medical screening examination was requested, and RN 5 stated, "I'll try to locate the MSE." No documentation of the patient's MSE or history and physical was provided.

Nurse Encounter Notes
On 1/29/2020 at 3:00 PM, review of the patient's recorded vital signs showed:
1/28/2020 at 2:41 PM: pulse: 60, respirations 14, Blood Pressure: 118/82, and SpO2 (Oxygen Saturation Level in lungs) 98% (percent) and on 1/28/2020 at 2:46 PM: pulse 55, SpO2: 91 %

Physical Therapy (PT) Encounter Notes
On 1/29/2020 at 3:10 PM, review of the physical therapy evaluation revealed "Assessment", "Pt (Patient) is a 55 yo (years old) male ..... in the ED since 1/28 after being found living in poor living conditions (DSS - Department of Social Services involved). PMH (Past Medical History) includes h/o (history/of) CVA (Cerebral Vascular Accident), multiple falls, recent heart cath after which hospice services were d/c'd (discontinued). PT is A&OX 3 (Alert & oriented times 3), following 1 step commands, presenting with no apparent cognitive deficits apart from slow responses. .....". In the section labeled "Functional Impairment", the therapist documented, "Decreased endurance, Decreased LE (Lower extremity) strength, Decreased LE ROM (Range of Motion), Decreased independence with bed mobility, Decreased independence with transfers, Decreased independence with gait, Decreased balance, Educational needs, Patient would benefit from skilled PT to address the noted problems."

Acute Care Occupational Therapy(OT) Encounter Note
On 1/29/2020 at 3:16 PM, review of the occupational Therapy encounter notes revealed "Assessment" that "patient is a 55 yo male presenting after being found in poor living conditions unable to care for himself. Prior to admission, patient was modified independent for mobility and ADLs (Activities of Daily Living). Recently had hospice that was discontinued 2*2 (secondary ) heart catheterization. Since hospice stopped coming, patient reports he has been unable to care for himself. Patient with functional decline resulting in overall mod/max (moderate/maximum) assist for ADLs (Activities of Daily Living). Patient will benefit from skilled OT to maximize independence and address listed functional impairments to decrease burden of care."
The patient was only evaluated by a physical therapist, occupational therapist, and a social worker in the emergency department.

Licensed Medical Social Worker (LMSW #1) Encounter Note
On 1/29/2020 at 3:10 PM, review of the patient's electronic medical record revealed LMSW #1 documented, "The patient reports he had hospice but they stopped coming after he had his heart cath (Catheterization) 2 weeks ago. The patient reports he needs assistance with his ADLs(activities of daily living). The patient reports that he has difficulty ambulating and really cannot ambulate. The patient reports that his balance is unsteady. The patient reports 3 falls within 2 months. The patient wears glasses but denies hearing loss. The patient reports that his doctor died two months ago. The patient reports that the last time he saw the doctor was 3 months ago. The patient reports problems getting his medications due to transportation and financial reasons. This SW (Social Worker) CM (Case Management) discussed this patient with ED physician #9 and informed the ED Physician #9 that the patient wants to go to a skilled nursing facility. The patient reports that he is not able to care for himself." On 1/29/2020 at 2:09 PM, LMSW #1 documented, "Patient has a bed offer at ..... pending insurance approval. LMSW has requested that they begin in the insurance process. Patient's insurance generally takes 1-2 business days to get approval. LMSW will continue to follow." On 1/28/2020 at 4:19 PM, documentation showed ED Physician #9 was informed of patient's condition and desire to go to a skilled nursing facility.

ED Medical Director Interview
On 1/29/2020 at 11:15 AM, ED Medical Director - Adults, stated, "The patient presented with chief complaint of Bad Living Conditions, and we have a lot of patients that come in under protective custody that just need placement somewhere." The patient was evaluated by physical therapy, Occupational therapy, and the Social Worker. Additionally, there was no medical screening examination documented in the chart. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #21 when he presented to the hospital's ED on 1/28/2020.

Greenville Health System Medical Staff Bylaws, "Adopted and approved by the Board of Directors on: 9/27/2016 to be effective on 10/1/2016. Updated on 9/26/2017 by Board of Directors changed name of "Allied Health Professional to Advance Practice Provider ' was reviewed. The Medical Staff Bylaws revealed in part, "Section 4. Consulting Category ... B. Prerogatives: A member of the Consulting category may. 1. Admit and/or treat patients and/or act as a consultant in accordance with privileges granted him/her by the Board ....C. Duties: The Medical Executive Committee is delegated the primary authority over activities related to the functions of the System (GHS) Medical Staff and performance improvement activities regarding the professional services provided individuals with clinical privileges. . . 3. Consulting with administration on quality related aspects of contracts

Based on medical record review, policy and procedure review, and ED(Emergency Department) Medical Director and staff interviews, the hospital's Emergency Department failed to ensure an individual determined to have an emergency psychiatric condition was provided within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition for 4(Patient #24, #16, and
#2, #17) of 25 patient charts reviewed for patients who presented to the hospital's emergency department with suicidal and homicidal ideation.

The findings included:

ED Patient #24
On 1/30/2020 at 9:55 AM, in the conference room, review of Patient 24's Electronic Medical Record(EHR) with Registered Nurse(RN) # 5 revealed the patient presented to the hospital's ED on 1/28/2020 at 11:30 AM with a chief complaint of Aggressive Behavior.
Medical Record Review
On 1/28/2020 at 11:30 AM, review of Physician #45's ED progress note revealed "presents to the emergency department after complaints of aggressive behavior and statements of self-injury ..... police officer reports that the patient became aggressive at the group home and used a slide from a drawer to attack the other people at the home, and then tried to cut his own wrist. Police also reports the patient said something along the lines of 'I want to end the pain before I hurt somebody else'. Patient 24's treatment in the ED included patient observations every 15 minutes for suicidal/homicidal/violent patient from 11:15 AM 1/28/2020 - 2:00 PM 1/28/2020, and medical treatment at 2:05 PM for a right wrist laceration with normal irrigation and dressing applied. Patient #24's chart showed "Discharge Date/Time: 1/28/2020 at 2:19 PM. Discharge Disposition: Home or Self Care."

On 1/30/2020 at 10:10 AM, RN #5 verified documentation in the patient's medical record that showed "After Visit Summary - Document dated 1/28//2020 at 12:43 PM by ED Physician #45" that reads, "You currently have no upcoming appointments scheduled, and Your Medication List is unchanged."
ED Medical Director - Adult
On 1/30/2020 at 10:30 AM, in the conference room, ED Medical Director - Adult reported, "He (Patient #24) did not have a psychiatric consult."
ED Director of Nurses #1 and ED Physician #7
On 1/30/2020 at 11:45 AM, Director of Nursing (DON) #1 revealed, "Yes, we take homicidal and suicidal patients in the Intensive Management Unit (patient unit in ED that is locked)." On 1/30/2020 at 3:55 PM, ED Physician #7 revealed, "Physician must evaluate. We have psychiatrist in the ED. I hired them." ED Physician #7 stated, "Yes, a homicidal and suicidal patient meets criteria to admit to hospital. Those are an EMC (Emergency Medical Condition), and we would observe that patient."
Director of Nurses for Inpatient Psychiatric Unit
On 1/29/2020 at 3:52 PM, Director of Nurses (DON) #21 verified that he/she is the Director of Nurses for the hospital's inpatient psychiatric unit that has 65 beds and that the psychiatric unit had a total of 41 inpatients in its psychiatric unit. Further review of the patient's medical record on 1/30/2020 at 3:00 PM revealed there were no instructions to the police officer to continue treatments for suicide precautions or homicide precautions after discharge from ED.

Patient #24's psychiatric emergency condition was not stabilized as evidenced by the hospital's failure to ensure the patient was evaluated by a psychiatrist, and the patient was not evaluated/managed by a psychiatrist prior to discharging the patient from the ED. The hospital was equipped with such staff, services, or equipment necessary to stabilize Patient #24's psychiatric emergency condition on 1/28/2020.





18581

ED Patient #16:
On 1/29/2020 at 09:50 AM, Patient #16's chart was reviewed with Registered Nurse (RN) #6 who verified the findings related to the documentation in the patient's chart.
EMS Run Report
On 1/29/2020 at 09:50 AM, review of Patient #16's emergency department chart revealed the patient presented to the hospital's ED on 1/27/2020 at 7:29 PM via Emergency Medical System (EMS) ambulance, and revealed "Arrived and found patient sitting up on the steps of a church. The patient stands and walks toward the EMS unit and relays that he has been out of his medicines for some time and has been doing Meth and alcohol last night, and today he has been hallucinating, feeling suicidal, and has a bad cough making his chest hurt. The patient is secured to the stretcher in a position of comfort. Report is called on route to the hospital. The patient reports no changes to complaints to ER (Emergency Room). The patient is triaged to room C 30. The patient is able to move from stretcher to bed with side rails raised up. Patient care and report are given to RN.(Registered Nurse)" On 1/27/2020 at 7:00 PM, EMS documented "blood pressure was 170/100, pulse 110, respiration rate 20, Oxygenation saturation level 99, and pain 6". On 1/27/2020 at 7:06 PM, EMS documented "blood pressure as 155/96, pulse 100, respirations 20 regular, oxygenation saturation level 95". Review of the EMS documentation for a four (4) lead electrocardiogram dated 1/27/2020 at 7:09 PM showed "Sinus Tachycardia (an elevated sinus rhythm characterized by an increase in the rate of the heart's electrical impulses). EMS documented "Impression: Suicidal Ideation and Chest Pain (non cardiac in nature)".
Triage Notes
On 1/29/2020 at 09:50 AM, review of Patient #16's triage note dated 01/27/2020 revealed the triage note had no time the triage was started, but showed an ESI (Emergency Severity Index scale of 1 to 5 with 1 being the most severe) level 2 (Emergent). In the section of the triage assessment form, labeled, "Confirmed/Updated Chief Complaint - dated Monday, 01/27/2020 showed "Chief Compliant Confirmed or Updated? Yes ". There was no other triage information documented.
Demographics
On 1/29/2020 at 09:50 AM, review of Patient 16's chart in the demographics notes section dated 1/27/2020 revealed the patient was not employed and had no active insurance coverage on file for 1/27/2020.
Nurse Intake Notes
On 1/29/2020 at 09:50 AM, review of the Nurse Intake Notes dated 01/27/2020 at 8:10 PM revealed Patient #16 was placed on suicidal precautions with continuous observations, sitters at bedside, and paper scrubs. Vital signs were documented at 08:09 PM as pulse: 112 and blood pressure: 140/96. Documentation revealed a room sweep for equipment risks was completed. Review of nurse notes dated 01/28/2020 at 2:50 PM revealed the patient is at "risk for suicide with current suicidal thoughts; individual has a specific plan for self harm; pt(patient) reports "If I go out there, Im[sic] going to kill myself." The registered nurse documented, "Suicidal/ parasuicidal thoughts, threats, planning; intense feelings of hopelessness; No support system; Patient verbalizes intent to harm self; Seeking relief from emotional pain; Single, alone, separated, divorced, widowed." In the section, labeled, "Rationale for Above Decision", the nurse documented "pt(patient) reported he is suicidal; pt is well known to ed (emergency department); pt. has hx of endorsing SI in an attempt to obtain shelter. Today, He is stating he is living with a roommate. ....".
ED Physician Provider Encounter Notes
Review of the physician encounter history and physical notes dated 1/27/2020 at 11:26 PM revealed Patient 16's chief complaint was "Suicidal paranoid and out of meds(medications)." The ED Physician documented "..... 31 - year - old male who presents complaining of suicidal ideation without a specific plan. He does admit to substance abuse. States he is homeless. Reports anxiety. Reports he has been out of his medicines for 2 or 3 weeks. Dates [sic] he supposed to be on Serroquel (Psychotropic medication treats Schizophrenia), Wellbutrin, and Remeron (both medications are Antidepressants). Denies any recent attempt to harm himself."
Review of the section in the history labeled "Review of Systems" revealed the ED physician documented "Positive for suicidal ideas. Negative for Hallucinations" and "Positive for cough". Review of the patient's physical examination notes documented by the ED physician revealed "Blood Pressure (BP)(!) 140/96 (BP Location: Right arm, Patient Position: Sitting), Pulse (!) 112, Resp(Respirations) 16, and SpO2 (Oxygen saturation level in blood) 100% (percent), Cardiovascular: Regular rhythm. Tachycardia present, Psychiatric: Somewhat pressured speech. No evidence of hallucinations. States he has suicidal ideation but no specific plan."
ED Course
"..... Room air oxygen saturation normal at 100% (percent). Laboratory studies include a urine drug screen which is positive for sympathomimetic amines. Chest x-ray with no pneumothorax or infiltrate. No cardiomegaly. Metabolic panel with no electrolyte abnormality. Alcohol level less than 10. CBC (Complete Blood Count) with no leukocytosis. No anemia with a hemoglobin of 15.2. Stable here in ED. Plan is observation overnight to allow him to metabolize his methanphetamine. ITC paperwork completed."
ED Physician Orders
Review of Patient 16's chart revealed ED Physician orders dated 01/28/2020 at 2:40 PM for a psychiatric consult and an order dated 1/28/2020 at 1:53 PM for a Psychiatric Social Worker consult. Patient #16 was ordered Suicide Precautions with sitters at bedside for suicidal ideation on 1/27/2020 at 7:48 PM.
Licensed Medical Social Worker (LMSW) #2's Consult
Review of Patient 16's chart revealed LMSW #2 documented: "Note: A psychiatric consultation was conducted at this time, as per emergency department protocol, given that the patient has been in the emergency department for greater than 8 hours and is, as per social work report, without any viable psychiatric disposition available at this time". LMSW #2 documented that he/she assessed the patient on 1/28/2020 at 3:06 PM and revealed the patient's chief complaint was "Suicidal paranoid and out of meds". LMSW #2 documented the following significant findings.
"Problems/Somatic Symptoms: Major life areas: PT (Patient) states, "If I go out there, I'm going to kill myself." pt. states it is not the drugs, that he has been clean before, and still felt suicidal. Pt. is well known to ED and has a hx(history) of endorsing SI (Suicidal Ideation) in an attempt to obtain shelter. Pt. states he has a roommate and provided an address. He indicates his roommate does not have a working (telephone) number. Pt. can not contract for safety. He feels he needs hospitalization. He indicates even if he had a place to go, he would still be suicidal. Pt has an eight year old which he does not see. He just recently lost his job for missing too many days. Behavior Changes: Poor Impulse Control, Irritability. Depression Symptoms: Feelings of Hopelessness, Feelings of worthlessness, Feelings of helplessness, Loss of interest. Delusions: ("I feel like people are following me.")". Mental Status: Depressed mood and poor judgement. Suicide Risk Evaluation and Protective Factors : LMSW #2 documented "the patient is at risk for suicide, has current suicidal thoughts, and has a specific plan for self- harm. In the section of the consult labeled "Risk factors for Imminent Suicidal Behaviors", LMSW #2 documented, "suicidal/parasuicidal thoughts, threats, planning, Intense feelings of hopelessness, No support system, Patient verbalizes intent to harm self, Seeking relief from emotional pain, Single, alone, separated, divorced, widowed. Patient's suicide risk judged to be mild and rationale for Above Decision: pt. reports he is suicidal. Pt is well known to ED. pt. has hx(history) of endorsing SI(Suicidal Ideation) in an attempt to obtain shelter. Today, He is stating he is living with roommate. .....".
ED Psychiatric Consult with Psychiatrist #42 dated 1/28/2020 at 3:22 PM
Review of Patient #16's psychiatric consult revealed "..... is a 31 y.o. (year old) male with documented history of methanphetamine intoxication, methanphetamine use disorder, benzodiazepine use disorder substance - induced mood disorder, posttraumatic stress disorder, major depressive disorder, brought in by EMS for suicidal ideation. Patient presented to the emergency department on a voluntary basis. ...... On face to face evaluation, patient reports he is not doing good and states it is hard for him to talk about his stressors. ..... The patient's primary focus is gaining access to psychiatric hospitalization instead of treatment." Review of the section labeled, Past Psychiatric History, revealed the patient had 2 or 3 suicide attempts with last one about 3 or 4 months ago when the patient overdosed, has a history of cutting, and the patient's last psychiatric hospitalization was in 2018. The patient's last outpatient mental health treatment was listed as 2014. Review of the section labeled, Self - Harm/Violence Risk Assessment, revealed "The patient is at risk of inadvertent harm to self and/or others in context if agitation likely related to his substance use, inability". In the section, labeled, Assessment, the psychiatrist documented, "Current examination does not reveal acute evidence of affective decompensation or psychotic decompensation. There is no acute evidence of substance intoxication or withdrawal based on current evaluation. The patient did not appear to meet criteria for psychiatric inpatient level of care. The patient's suicidal threats appear to be his means to gain access to lodging through setting as he is not interested in any other treatment modalities. The patient's character structure makes him at risk to engage in activities to gain hospitalization or be admitted for non- clinical reasons. He is more interested in hospitalization than treatment and he remains forward - thinking and future - oriented. There is no acute evidence of a risk of violence emanating from mental illness. Given that he is unable to contract for safety at this time, suggest continuing to hold patient in the emergency department on ITC and reassess in a.m. and have staff from FAVOR(outpatient treatment) meet with him." Review of the section labeled, Plan: revealed the psychiatrist documented "Continue to hold patient on ITC, continue current observation status as per ED protocol, Psycho-education provided to patient regarding importance of abstaining from illicit substances and adverse effects associated with continued use including risk to self and others, Plan to have staff from FAVOR(psychiatric outpatient services) meet with patient in a.m., The patient received a single dose of mirtazapine 15 milligrams (antidepressant), quetiapine 100 mgs (medication used to treat Bipoliar), and Wellbutrin SR 100 mgs on 1/27/2020. Will not continue these medications due to patient's history of treatment nonadherance, until his medications can be verified by ED pharmacy, Nicotine patch 21 mgs, as per patient's request, and I have discussed the case with the ED physician who has verbalized agreement and understanding."
Inpatient Psychiatrist Unit's Census Report
On 1/29/2020 at 3:52 PM, the survey team requested the inpatient psychiatric unit's criteria for admission from the Director of Nurses for the hospital's 65 bed PPS psychiatric unit, but the hospital did not submit this criteria. Review of the hospital's census report for its 65 bed inpatient psychiatric unit showed a census of 39 inpatients on 1/27/2020, 36 inpatients on 1/28/2020, and 37 inpatients on 1/29/2020. The patient had not been discharged nor transferred as of 1/30/2020 and was still in the emergency department. The psychiatric consult or screening examination was not conducted per the hospital's Rules and Regulations.

Patient #16 was not stabilized prior to disposition. There is no indication what the disposition of the patient was. The patient had a psychiatric emergency condition. The psychiatrist wanted to keep the patient on an involuntary hold. The patient was not admitted to the hospital despite the hospital having available beds left in the emergency department for an unknown period of time. The patient was not stabilized prior to disposition.

Hospital policy, titled, "Medical Screening Examination and Stabilizing Treatment, Policy, approved by the Governing Body on July 11, 2017 was reviewed. The policy revealed, in part, "1. Policy: Medical Screening Examination and Stabilizing Treatment . . . If an EMC is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the GHS Hospital where the individual presents, or an appropriate transfer in compliance with EMTALA(Emergency Medical Treatment And Labor Act).









39310

ED Patient #2 (No Psychiatric MSE)
Patient #2 presented to Hospital #1's Emergency Department on 4/30/2019 at 13:11 PM via car with grandparents.

Triage Nurse Notes 4/30/2019 at 1:14 PM
"Per grandmother, 'He has been exposed to a tremendous amount of abuse. We have had custody since September 7th. He has aggression and physical violence towards others. He choked his brother this morning until he passed out.' Pt denies SI/HI(Suicidal Ideation/Homicidal Ideation) at this time. Pt(Patient) calm and cooperative in triage. Call in note: 8 yo(year old) Male, increasing violent behavior. Has molested his cousin x(times) 3 in the last week - has been reported. Tried to strangle his brother. Patient's brother was killed by Mother's boyfriend. DSS(Department of Social Services) involved. Maternal Grandparents have custody. Coming from internal medicine via POV (Private Owned Vehicle)."
Chief Complaint: Aggressive Behavior; Homicidal

ED Physician Provider Note dated 4/30/2019 at 1:33 PM
"The patient is a 8 y.o. generally healthy male who presents to the ED for aggressive behavior. He currently lives with his grandparents. His grandparents report he currently has been exhibiting increasingly violent behavior. He will spontaneously hit his siblings and cousins. He has also taken rocks and thrown at his siblings and cousins. .....His grandparents learned that he has been molesting his 4 y/o female cousin for at least a week. The molestation was reported to the police and social services this morning. He has a history of anti- social personality, ADHD (Attention Deficit Hyperactivity Disorder- a mental health disorder, combination of persistent problems), and dissociative disorder. He also has a history of PTSD (Post Traumatic Stress Disorder) due in part to witnessing his younger brother's abuse and murder. A consult with the ED's psychiatric social worker was placed at 1:54 PM.

LMSW Evaluation ED 4/30/2019 at 5:31 PM
"Involuntary Hold (Emergency Hold-is a brief involuntary detention of a person presumed to have Mental Illness) Start 4/30/2019 at 13:45 PM and Expiring 4/30/2019 at 1:35 PM. Chief Complaint Aggressive Behavior/ Homicidal. Pt(Patient) is a 8 y.o. male presented to ED after choking his brother almost to the point of passing out. Patient's risk for homicide is rated severe since pt presented to ED after choking brother. Per pt's grandparents, pt is aggressive and impulsive."
Plan: "SW(Social Worker) collaborated with ED MD and ED Psychiatrist. PT placed on WP(White paper). SW to assist with inpatient psychiatric placement." Patient #2 was never evaluated by a psychiatrist. The hospital failed to ensure that Patient #2 received a psychiatric assessment/evaluation by Qualified Medical Personnel.

Patient #2 was placed on an involuntary hold at 1:45 PM. A psychiatric consultation order was placed at 1:54 PM. The social worker evaluated the patient at 1:35 PM, but the patient was not evaluated by a psychiatrist. The social worker relayed the findings to the psychiatrist. Patient #2 was transferred for psychiatric management to another facility. The patient was not stabilized prior to transfer, and the transfer paperwork was inaccurate in stating that the hospital did not have the capability of managing the patient.

Patient #9
Review of Patient #9's chart on 1/29/2020 at 1:00 PM revealed the patient presented to Hospital #2's Emergency Department(ED) on 12/27/2019 at 07:44 AM by ambulance from an area nursing home where the patient was receiving rehabilitation therapy after a recent hospitalization for Pneumonia. Review of the patient's chart received from Hospital #1 revealed the patient has a history of end-stage renal disease and was due for a dialysis treatment this morning, had shortness of breath all night, and this morning began to complain of acute severe chest pain. Documentation in the chart showed the patient was in severe distress and diaphoretic. Based on the patient's symptoms, the patient was transported emergently to Hospital #1."

Triage
Review of the triage nurse notes dated 12/27/2019 at 07:50 AM revealed the patient received an Electrocardiogram 12 lead, vital signs were documented as: Temperature 98.3 F (Fahrenheit), Heart Rate 115!, Blood Pressure 183/141!, and SpO2(amount of oxygen in the blood) 100%(percent) with 4 liters oxygen via nasal cannula. The patient was assigned an ESI (Emergency Severity Index) acuity level of 2 (scale with 1 requiring the most intense services and 5 requiring the least intense services), placed on cardiac monitoring, and a oximeter to measure the patient's oxygen saturation level.

ED Physician History and Physical
ED Physicians History and Physical dated 12/27/2019 at 09:46 AM revealed, "This is a petite and frail appearing Hispanic female in severe distress. This patient is ashen in color and diaphoretic. Auscultation reveals a Tachycardia regular rate and rhythm. There is a 3/6 systolic ejection murmur on the left sternal border. Respirations are moderately to severely labored. Auscultation reveals rales about halfway up in both lung fields. Management options: at this time, the patient is noted to be severely Hypertensive. Patient started on high-dose Nitroglycerin drip to bring blood pressure down. I have asked the unit coordinator to confirm that our nephrologist is in town as the patient will require emergent dialysis in the ICU(Intensive Care Unit). Patient will be given IV(Intravenous) morphine along with high dose nitroglycerin and the patient has already received aspirin prior to arrival."
"8:30 AM: the patient has been re-examined. The patient is still having significant respiratory distress. My ultrasound exam as well as chest x-ray confirmed significant pulmonary Edema and the patient also has history of scleraderma and restrictive lung disease. Therefore, believe the patient could benefit from BiPAP which is being ordered at this time. 9:30 AM: the patient's work up returns with lab studies is documented: Initial troponin is 0.06. Sodium is 127 and creatinine is 2.4. With initial troponin elevation, I will re-contact the physician to see if he still endorses the patient staying here for treatment. The patient is symptomatically improved on nitroglycerin drip and chest x-ray shows increased infiltrated process suggestive of a pulmonary edema or pneumonia and the patient also has known connective tissue long disease. 9:45 AM: I spoke with the physician at 9:31 AM and he felt the patient continue to stay for treatment and our hospital despite an initial troponin of 0.06. He feels that this does not represent STMI(An ST-segment elevation myocardial infarction. A serious form of heart attack in which a coronary artery is completely blocked and a large part of the heart muscle is unable to receive blood), and that the patient does not require acute intervention. Patient is symptomatically approved[sic] at this time. I have confirmed that the nephrologist is in town and available. I will now contact the hospitalist to request admission. 10:45 AM: I contacted the hospitalist for admission of this patient. He informed me that he had just spoken with a nephrologist and he was en route to Arizona to attend the football playoff game. Despite numerous calls to the nephrologist office reassuring me that he was available, I have contacted him directly, and he informed me that he is out of town, and the patient will have to be transferred. I will now inform the patient's family of this change and contact the referral center to attempt transfer. 11:46 AM:. The ICU Intensive Care Unit) hospitalist service has contacted me, and I have discussed the case at length with him. He agrees to except[sic] this patient and transfer to there. As soon as we are notified of the patient's bed number, she will be transferred by EMS.


ED Patient #17
On 1/29/2020 at 09:50 AM, Patient #17's chart was reviewed with Registered Nurse (RN) #6 who verified the findings related to the documentation in the patient's chart.

EMS(Emergency Medical Services)
On 1/29/2020 at 10:15 AM, review of Patient #17 ED chart revealed the patient presented to the hospital's ED on 1/28/2020 at 3:24 PM via EMS for "Psychiatric Evaluation "and auditory hallucinations.

Triage Encounter Notes 1/28/2020 3:26 PM
On 1/29/2020 at 10:30 AM, review of the nurse triage notes revealed "Arrives via EMS with c/o (complaint /of) auditory hallucinations, hx (history) of PTSD (Post Traumatic Stress Disorder), pt was running around outside with a knife, denies SI/HI(Suicidal Ideation/Homicidal Ideation), positive ETOH (Alcohol). There was no documentation of a triage level assigned to the patient.

Physician Orders
Review of physician orders dated 6:55 PM on 1/28/2020 revealed the patient was ordered observation with sitters at bedside for "at risk for violence - psychosis", and an ED consult to Psych Social Worker on 1/28/2020 at 3:49 PM.

Medical Screening Examination by ED Physician on 1/28/2020 at 3:38 PM
Review of the Medical Screening Examination revealed "..... is a 30 y.o. male with a past medical history of PTSD who presents emergency department for psychiatric evaluation. Patient was brought in by EMS(Emergency Medical Services) earlier today after patient was seen running around outside with a knife. Patient states that he has been "wigging out" for approximately 1 week. Patient reports that he is in the Special Forces for the United States and United Nations who is on a special mission for spiritual warfare. Patient states that he was running around with a knife today because he was summoning spiritual beings to destroy them. He states he would not hurt any humans. He had no intent on harming himself or others. Patient also states that he has been experiencing auditory hallucinations in the form of a speaker that has been implanted in his right ear that connects to a satellite. Patient states that the general of the United States talks to him through that speaker. Patient states that he does drink alcohol daily, and he has drunk one half of a pint of liquor today. .....he denies any associated SI or HI." Review of the section, labeled, Review of System, revealed, "Psychiatric Behavior: Positive for behavioral problems, confusion and hallucinations." Review of the section labeled, Physical Exam, revealed, "Psychiatric: He has a normal mood and affect. His speech is normal. He is actively hallucination. Thought content is delusional. Thought content is not paranoid. He expresses no homicidal and no suicidal ideation. "
Differential Diagnosis: includes but is not limited to new onset Schizophrenia, Bipolar, Depression, Hypoglycemia, other electrolyte abnormalities, other infectious etiologies....Patient was transferred over to behavioral health (located in the hospital's emergency department), and will further receive treatment there. Review of the hospital's census for its 65 bed inpatient psychiatric unit showed the census on 1/28/2020 was 31, and the bed census was 33 on 1/29/2020.

Licensed Medical Social Worker (LMSW) Screening
There was a psychiatric screening conducted by LMSW #2 on 1/28/2020 at 6:41 PM. Review of the LMSW's progress notes revealed "PLAN-SW (Social Worker) reviewed with ED MD &(and) (psychiatrist). Pt. has been placed on ITC and will need to be reassessed later. "The patient's insurance was listed as self-pay. The facility failed to ensure that Patient #17 received a psychiatric assessment by Qualified Medical Personnel.

Psychiatric Screening Examination
There was no documentation of a psychiatrist consult in the patient's chart to assess the patient for the existence of an emergency psychiatric condition or the need for further treatment. The hospital failed to ensure that Patient #17 received a psychiatric evaluation by Qualified Medical Personnel and stabilizing treatment. There was no documentation of the patient's disposition.

Based on the review of patient medical records, EMS Run Report review, policy and procedure review, bed census report review, and interviews, the hospital failed to provide further medical evaluation and treatment required based on the individual's source of payment, the hospital failed to admit 1 (Patient #3) of 25 sampled patient records reviewed due to lack of insurance.

The findings are:

ED Patient #3
On 1/28/2020 at 10:00 AM, review of Patient #3's Emergency Department chart revealed the patient arrived via EMS(Emergency Medical System) transportation on 1/26/2020 at 9:20 PM for suicidal ideation.

EMS Run Report
Review of the EMS run report dated 1/26/2020 revealed the primary complaint was suicidal ideation. EMS personnel documented "Found patient sitting in her room, states she and her Mom have been fighting, and states
that she wants to die, Pt.(Patient) States she told her Mom that she was she was going to kill herself, Mom states she found her suicide letter, and states that her daughter had locked herself in the room and said that she had a razor blade. Pt. states that she calmed down now, and states she will cooperate with Police and EMS ...".

Triage Note
Review of the nurse triage notes dated 1/26/2020 at 8:38 PM revealed "Suicidal ideation with a razor blade, cutting. Child has written letters with suicidal intent-". The patient's vital signs were documented but no triage ESI level was documented.

History and Physical at 1/26/2020 at 12:07 AM
Review of Patient 16's chart revealed the patient's history and physical showed "..... a 16-year-old female that identifies as a male that was found today writing a suicide note to his friends with razor blades next to him. He had a notebook with several ideas how he would end his life. he denies any active thoughts today of ending his life. He states he wrote a note because all of his friends are suicidal and they are writing these types of notes. The patient admits to previously hearing voices that tell him to hurt himself. they didn't tell him that today. He said he was scared of this voice and what it tells him. He also states he previously has had visual hallucinations of a black dog. Patient endorses feeling of not needing to sleep with excess energy intermittently. He states he doesn't see any counselor but will talk to his friends about his feelings. The mother is in the room and crying during the encounter. She keeps referring to the patient with female pronouns during the encounter even after the patient stated he thinks he is a male." Clinical impression: suicidal ideation. "Plan: patient is a is a 16 y.o. female that identifies as male presents after being found writing a suicide note with razors at the bedside. Patient denies any active plans of ending his life but is very evasive when I ask these questions. He will actively engage in conversation when asked about school, theater, club. The patient has old cut marks on the left forearm but denies any recent cutting behavior. He does state he hears a voice that tells him to kill himself and he is scared of this voice. We will obtain urine pregnancy test. At this time the patient denies any drug use. We will have psych social work assess the patient. The patient is denying active suicidal plans but states all of his friends are suicidal and feels like he would need to kill himself if they were to commit suicide. He is also at a higher risk of suicidal behavior due to his transgender status."

Physician Orders
Patient observations every 15 minutes for suicidal/homicidal /violent patient every 2 hours for protection from injury , Using screen for pregnancy, urine drug screen, and Psych social Work consult

LMSW(Licensed Medical Social Worker) Consult 11/27/2020 at 7:53 AM
Psychiatric consult ordered on 11/27/2020 at 10:.41 AM. Documentation revealed the LMSW Consulted on 11/26/2020 at 01:30 AM and review of the LMSW Consult Notes dated 11/27/2020 at 7:53 AM revealed "patient as a is a 16 y.o. female that identifies as male that was found writing a suicide note to his friends with razor blades next to him. Mother reports pt. had a notebook with several ways of how he would end his life. Pt denies active thoughts today of ending his life however stated he was angry yesterday about how his mother does not accept his transgender and therefore had suicidal thought and wanted to be prepared just in case he decided to kill himself one day. ..... Pt reports he hears voices commanding him to kill self and that he was worthless. Len the section labeled, Suicide Risk, the LMSW documented "yes." The LMSW documented "Plan: SW reviewed with ED provider, patient placed on commitment papers, to be referred out for treatment. Review of the clinical notes per the LMSW dated 11/27/202 O al 10:40 AM revealed "Patient seen by psychiatry team and continues holding for psychiatric admission. No beds locally or statewide. Patient on wait list for ..... (State psychiatric hospital).

Consult to psychiatry on 1/27/2020 at 10:41 AM
Psychiatric consultation performed: 1/27/2020 11:24 AM
Review of the psychiatric consultation dated 1/27/2020 at 11:24 AM revealed Plan: I am in agreement with the recommendations and treatment plan created by the psychiatric social worker. It is recommended that the patient remain on white papers. Social worker will continue to seek placement at a psychiatric facility for this patient. No psychotropic medications will be started for this patient at this time. Please reach out to psychiatry for any questions or concerns. Review of the psychiatrist notes dated 1/28/2020 revealed
"Plan: It is recommended that the patient remain on white papers. Social work will continue to seek placement at a psychiatric facility for this patient. It appears evident that the hospital's 65 bed inpatient psychiatric unit are currently full. BARRIER TO PLACEMENT IS THAT THE PATIENT IS UNINSURED. No psychotropic medications will be started for this patient at this time. Supportive psychotherapy provided. Will continue to reach out to the patient's family. Patient transfer information: 1/28/2020 at 3:07 PM. Patient has been accepted for psychiatric hospitalization at ..... (State Psychiatric Hospital)".

Face to face interview with LMSW #1 at 1/30/2020 11:32 AM
"I work in the emergency room only. I work 9:30 AM to 9:30 PM. I see the patients that come from facilities, home health, hospice, homeless shelters, etc. We have an assessment sheet. We asked the questions, cover all the information on the assessment. We may need to call the facility or family for assessment. This is documented in the computer. The emergency doctor decides if there is altered mental status. They consult the psychiatrist to see the patient. We talk with the emergency room doctor and psychiatrist and give them the information we gathered. If we request the psychiatrist, then they will see the patient. The psychiatrist will talk to the emergency room doctor. The psychiatrist in the emergency department has 24 hours a day, seven days a week coverage. There is one psychiatrist and they see the ones (patients) waiting to go to an area. They may not get to the consults within the time because they have so many patients to see. Do you refer patients to the hospital's inpatient psychiatric unit? LMSW # 1 stated, "Yes, if they accept that insurance, they take the patient right away."

Bed Census Data
Hospital census data for the hospital's adolescent inpatient psychiatric unit on 1/26/2020 revealed adolescent unit had 11 licensed beds with 6 beds occupied. Hospital census data for 1/27/2020 revealed a census in the adolescent unit of 6 occupied beds. Review of the Hospital census data for 1/28/2020 revealed a census of 4 occupied beds in the adolescent unit. Based on the data submitted by the hospital, the hospital's inpatient adolescent psychiatric unit had the capacity to admit the patient instead of holding the patient in the ED waiting for a transfer to another facility.

The Greenville Health System Medical Staff policy on Emergency Services (EMTALA) Transfers, On-Call Physicians, and Approved by the Board of Directors: July 11, 2017 was reviewed. The policy specified in part,
"VI. No delay in Medical Screening or Examination
a. An MSE(Medical Screening Examination), stabilizing treatment, or appropriate transfer should not be delayed to inquire about the individual's method of payment or insurance status. However, GHS may follow reasonable registration processes for individuals for whom examination or treatment is required. Reasonable registration processes may include asking whether the individual is insured, and if so, what that insurance is, as long as these procedures do not delay screening or treatment or unduly discourage individuals from remaining for further evaluation.."

The hospital failed to admit Patient #3 when the hospital's census report verified the hospital's inpatient psychiatric adolescent unit had available beds. The hospital adolescent unit submitted bed census data that showed the hospital's inpatient adolescent psychiatric unit had the capacity to admit, but Patient #3 was not admitted based on the individual's lack of insurance.

Based on medical record reviews, policy and procedures, EMS run report reviews, bed census reports, the hospital inappropriately transferred individuals when they failed to provide medical treatment within its capacity that minimized the risk to the individual's health for 4 (Patient #2, #3, #6, and #24) of 25 medical records reviewed . The hospital had the capacity to treat these individuals and this resulted in inappropriate transfers.

The findings were:





39310


ED Patient #3
Cross Reference to A 2408: Based on the review of patient medical records, EMS Run Report review, policy and procedure review, bed census report review, and interviews, the hospital failed to provide further medical evaluation and treatment required based on the individual's source of payment, and the hospital failed to admit 1 (Patient #3) of 25 sampled patient records reviewed due to lack of insurance
Bed Census Data
Hospital census data for the hospital's adolescent inpatient psychiatric unit on 1/26/2020 revealed adolescent unit had 11 licensed beds with 6 beds occupied. Hospital census data for 1/27/2020 revealed a census in the adolescent unit of 6 occupied beds. Review of the Hospital census data for 1/28/2020 revealed a census of 4 occupied beds in the adolescent unit. Based on the data submitted by the hospital, the hospital's inpatient adolescent psychiatric unit had the capacity to admit the patient instead of holding the patient in the ED waiting for a transfer to another facility.

ED Patient #2
Cross Reference to A 2406: The hospital failed to ensure that appropriate medical screening examinations were provided within the capability of the hospital's Emergency Department (ED), to include the ancillary services (Psychiatric Services) of Qualified Medical Personnel routinely available in the Emergency Department to determine whether or not an emergency psychiatric condition existed for Patient #2. Additionally, the hospital's Medical Staff Rules and Regulations failed to state that Licensed Clinical Social Workers were determined qualified to conduct psychiatric screening examinations.
Bed Census Data
The medical record indicated that the hospital under review had an inpatient adolescent unit with a bed capacity of 7 with only 5 beds filled.

ED PATIENT #6
On 1/26/2020 at 22:29, 11-year-old girl presenting for aggressive behavior and acting out at home. She was screaming and trying to hurt people. She required restraint in the ambulance on the way here, but on arrival was calm and directable and was able to give a history. Consult to psychiatry ordered 1/27/2020 at 10:42 AM. Psychiatry consult done 1/27/2020 at 12:33 PM . Patient placed on involuntary hold in ED. The patient was accepted for transfer 3 days later at another facility. Hospital #1 has an adolescent inpatient psychiatric unit with a capacity for 7. Review of the bed census report for 1/26/2020 and 1/27/20 showed a census of 6. The patient was inappropriately transferred to another psychiatric facility for continued stabilization when Hospital #1 had the capacity and capability to treat the patient.


Policy
The Greenville Health System Medical Staff policy on Emergency Services (EMTALA) Transfers, On-Call Physicians, and Approved by the Board of Directors: July 11, 2017 was reviewed. The policy specified in part,
"VI. No delay in Medical Screening or Examination
a. An MSE(Medical Screening Examination), stabilizing treatment, or appropriate transfer should not be delayed to inquire about the individual's method of payment or insurance status. However, GHS may follow reasonable registration processes for individuals for whom examination or treatment is required. Reasonable registration processes may include asking whether the individual is insured, and if so, what that insurance is, as long as these procedures do not delay screening or treatment or unduly discourage individuals from remaining for further evaluation.."




39463

ED Patient #24
Cross Reference to A 2406: On 1/30/2020 at 11:03 AM, review of Patient #24's chart revealed the patient presented to Hospital 1's Emergency Department via ambulance transport with a chief complaint of "Aggressive Behavior" on 1/28/2020 at 11:07 AM. Review of the nurse triage note dated 1/28/2020 at 11:08 AM revealed,"Pt (Patient) autistic. states he was grounded which made him mad. grabbed a sliding bracket out of his dresser drawer and hit 2 staff members and bit another staff member. Pt has some abrasions on his knee, arms, and head from the altercation. denies SI (Suicidal Ideation). comes from a group home special needs." The triage nurse assigned an ESI (Emergency Severity Index) Level 2 (Emergent) to the patient. On an ESI scale of level 1 to level 5, level 1 is defined as the most serious level and level 5 is defined as the least serious level."
Bed Census: Review of the hospital's bed census for 1/28/2020 revealed a census of 31, staffed bed capacity of 41, and total certified beds of 65. The patient did not receive a medical screening examination or evaluation from a psychiatrist and was not stabilized prior to discharge or admitted for further treatment.

Based on the patient medical record reviews, taped conversation reviews, Referral Center Log review, Emergency Medical Treatment And Labor ACT (EMTALA) policies and procedures review, Urology Physicians meeting, bed census report review, and on-call schedule review, and interviews, Greenville Memorial Hospital (Regional Referral Hospital #1) refused to accept individual(s) from a referring hospital based on an orally communicated community call plan, which resulted inappropriate transfers of individuals who required such specialized capabilities (Urology) and facilities as the hospital had the capacity to treat 2 of 2 patients who required emergent urologic services. (Patient #11, and #12)

The findings are:

ED Patient #12
On 1/29/2020 at 11:30 AM, review of Patient #12's chart revealed the patient presented to Hospital #4's (Transferring Hospital) Emergency Department(ED) on 5/ 21/ 2019 at 1:58 AM via ambulance transport for nausea, vomiting, and abdominal pain.

Triage (Hospital #4 - Transferring Hospital)
Review of the triage notes revealed the patient was assessed at an ESI(Emergency Severity Index) acuity level of "Urgent 3", Pulse 114, White Blood Cell (WBC), Blood Cultures ordered, Ringers Lactate intravenous ordered, antibiotics, and CT (Computerized Tomography) Abdomen and Pelvis without contrast revealed "Moderate left Hydronephrosis related to a 7 mm (millimeter) stone within the proximal ureter. A number of additional nonobstructing bilateral urinary calculi present right greater than left. The bladder is partially decompressed and now contains layering hyperdense material which represent contrast from an outside study. The appearance is atypical for layering stones."

ED Physician Encounter (ED Physician #10 - Hospital #4 - Transferring)
"Patient has history of stroke with aphasia. History of kidney stones. Patient required standing to the right. (That stone was infected). Patient became restless tonight. Acting like he is in pain. Patient has left-sided 7 MM (millimeter)kidney stone with Hydronephrosis(condition characterized by excess fluid in the kidney due to back of urine). Patient has now developed a temp(temperature) of 100. WBC 15.3. Patient tachycardic. Patient wears a condom Cath, but urine specimen was from and in (and) out cath. Patient given Rocephin(antibiotic) and IV (intravenous) fluids. Patient did not get contrast for the scan. Lactic acid was ordered when criteria was met. Lactic acid 4.6 (normal range 4.5 to 19.8 milligrams per deciliter). Patient is a smoker. Calcium 11.3. Hemoglobin 17.7. Request to speak to urology attending. The physical examination revealed in part ..."Abdominal soft ...He exhibits no distension and no Mass. There is tenderness, there is no rebound, no guarding. Oriented to person, place and time ...ED course 5/21/2019 0159 Pt.(Patient) now meets SIRS(Systemic Inflammatory Response Syndrome) criteria, heart rate 114.
0159 AM- Family request to go to (Hospital #1-Regional Referral Hospital). 0341-D/W (discussed/with) Regional Referral Hospital #1's Urology on-call - will not accept Pt.(patient) in transfer. D/W wife who refused to go to (Hospital #2 ) will D/W Urology again.
03:15 AM, Hospital #4's ED Physician #10 called PA #1 (Physician Assistant for Urology Group at Regional Regional Referral Hospital #1). Per PA #1, per community call protocol system, Hospital #2 (Another Hospital within the hospital system's community call plan) is to take the patient for Urology.
03:16 AM, ED Physician #10 from Hospital #4(transferring hospital) called the Urologist MD(Medical Doctor) #8 at Regional Referral Hospital #1.
06:35 AM, Urologist MD #8 (Urologist from Regional Referral Hospital #1) requested to speak with ED Physician #10 from Hospital #4(Transferring Hospital for Patient #12). ED Physician #10 from Hospital #4 (transferring hospital)recorded, "Will request transfer to Regional Referral Hospital #1 with Urology again.
0658 AM- BP (Blood Pressure) has dropped to 88 sbp (Systolic Blood Pressure) Dilaudid (pain medication), IVF (Intravenous Fluid) hung, wife paged to discuss transfer to Hospital #2 or Hospital #3. D/W wife as patient has hypotension (Low blood pressure), pt. needs transfer and should not delay. Still no beds at Regional Referral Hospital #1 and not accepting. Pt. wants to go to Hospital #3 ...Clinical Impression: Sepsis ... Urethral stone with Hydronephrosis, and AKI (Acute Kidney Injury)."
07:02 AM, patient has Hypotension (low blood pressure), patient needs treatment and should not delay. Still no beds at Regional Referral Hospital #1 and no accepting of patient. Patient wants to go to Hospital #3, paged Hospital #3."
07:14 AM, ED Physician #10 from Hospital #4(transferring hospital) called MD #11 at Hospital #3. ED Physician #10 reviewed the patient's information with MD #11 at Hospital #3. Patient on Levofed drip (medication used to treat life threatening low blood pressure). Patient #12 accepted and transferred to Hospital #3.

Hospital #1 - Referral Center Log
Review of Regional Referral Hospital #1's "Referral Center" log dated 5/21/19 at 2:17 AM revealed a telephone call was received from Hospital #4 requesting a transfer for Patient #12 to Regional Referral Hospital #1's Urology Group. The Referral Center from Regional Referral Hospital #1 explained its process as: "as outlined by MD(Medical Doctor) #_____from recent conversation about calling about calling Urology for patients and if Community Hospital #2's Urology would like to speak to Regional Referral Hospital #1's Urology Group, the hospital can call them.
02:21 AM, a call to Hospital #2's urology number was left on the doctor's beeper.
02:31 AM - call received from ED MD #10 at Hospital #4 - Transferring Hospital.
02:31 AM - call received from ED MD#10 at Hospital #4 - Transferring Hospital. Information entered from the Referral Center revealed, "Pt. has hx ( history) of stroke with aphasia. Hx of Kidney stone seen by (Named MD) (that stone was infected). Pt. became restless tonight. Acting. Like he is in pain. Pt has left 7 MM(millimeter) kidney stone with Hydronephrosis. Pt. has developed at temp 100, WBC(White Blood Cells) 15.3 (normal 4,000 to 10, 000), tachycardic, Pt. wears condom cath (catheter) but urine spec (specimen) was from in and out catheter ... Lactic Acid ordered. . . Calcium 11.3 (Normal range is 8.6 - 10.3 mg/dl), HGB (Hemoglobin) 17.7 (Normal Range 13.5 to 17.5 grams/deciliter), Request to speak to Attending Urologist. (Regional Referral Hospital #1) ...
3:15 AM: Call to PA(Physician Assistant) #1 ... PA #1 stated, Per PA #1, Per Protocol (Hospital #2) Urology is to take Pt. Discussed with Dr. Urology MD #38 - He will speak to ED MD #10 (Hospital #4 - transferring hospital)...
03:16 AM:. Urology MD #38 for ED MD #10 - discussing Dispo (Disposition) ED MD #10 to speak with patient wife to decide Dispo(Disposition) ...
0635 AM: Call to ED MD #10. . . Referring Provider. Urology MD #38
5/21/2019 -0714 Call to MD -Accepting Hospital (Hospital #3 - accepting hospital) Pt. Info(information) reviewed with MD accepting Patient 12 at Hospital #3. ED MD #10: Pt. now on Levophed Drip. Pt. being transferred to Hospital #3 (accepting hospital). The Regional Referral Hospital #1 refused to accept an appropriate transfer of Patient #12 on 5/21/2019 based on an orally communicated community call plan.

Hospital #1 Bed Census
The bed census report for the Regional Referral Hospital #1 was reviewed for 5/21/2019. The bed census report verified that the hospital's Intensive Care Unit(ICU) census was 28 with 1 ICU bed available. The hospital had the capacity to accept Patient #12 on 5/21/2019.

Hospital #1 On-Call Schedule
Review of the hospital's "Regional Urology Call Schedule" verified that on 5/21/2019, the first and second on call Urologists were on call and available when the request was made to transfer Patient #12 to the Regional Referral Hospital #1. The Regional Referral Hospital #1 had the capability (Urology Services) to accept Patient #12 on 5/21/2019.

The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to accept Patient #12 on 5/21/2019, delayed appropriate treatment for his identified Emergency Medical Condition (EMC); as the hospital was equipped with such staff services (Urology Services), and equipment necessary to stabilize the patient.



41879

ED Patient #11
Emergency Department(ED) Hospital #4 (Transferring Hospital)
On 01/29/2020 at 4:00 PM, review of Patient #11's chart revealed the patient presented to Hospital #4's emergency department on 07/04/2019 with sepsis (a potentially life threatening condition caused by the body's response to an infection), temperature: 102.7, Tachycardia, and leukocytosis. A CT (Computerized Axial Tomography)scan revealed a 4 mm(millimeter) stone and Hydronephrosis(Condition characterized by excess fluid in the kidney due to back of urine). Documentation showed ED Physician #5 performed a medical screening examination and stabilized the patient within Hospital #4's capability. When ED Physician #5 determined Hospital #4(transferring hospital) did not have the capability to treat the patient, the patient requested transfer to Regional Referral Hospital #1.

Telephone Referral Request from Hospital #4
On 07/04/2019 at 7:44 PM, ED Physician #5 called Regional Referral Hospital #1's referral line and requested a transfer per the patient's request. At 7:49 PM on 07/04/2019, documentation showed Registered Nurse(RN) #7 answered the call from ED Physician #5 at Hospital #4. The taped telephone conversation is as follows: "This is RN (#7)." ED MD #5 from Hospital #4 stated, "Hey this is ED MD (#5) at Hospital #4. How are you? I need to speak to ...I know I am at Hospital #4 but I need to speak with urology for a patient with a Urinary Tract Infection (UTI) with sepsis and a retained stone who does not want to go to Hospital #2." RN #7 replied, "The patient is (name of patient)? They (urology) are going to tell me that they do not take call for Hospital #4." ED Physician #5 stated, "Okay, so we are no longer allowing the patient to choose at all?" On 07/04/2019 at 7:50 PM, documentation revealed RN #7 contacted PA(Physician Assistant) #1 for the Urology Group via the referral line, "Hey this is .....(RN #7). I know you don't take call for Hospital #4 but he (ED Physician #5) needs to talk with you because he has to put it on record. Patient does not want to go to Hospital #2. I said they are going to tell me they don't take call for Hospital #4 but he was like get her on the phone ...okay." At 7:52 PM on 07/04/2019, ED Physician #5 spoke with PA #1(Urology Group) and stated, "Hey, ok just a question for you. We have a lady ...I'm at Hospital #4, but this lady does not want to go to Hospital #2. She has UTI(Urinary Tract Infection), and sepsis with retained stone. So I don't know how this works but we absolutely can't transfer to you at Regional Referral Hospital #1? Patient says she does not want to go to Hospital #2." PA #1 replied, "Yea, the only thing she would be getting is a hospitalist admission with a urology consult. The Urologist group covers Hospital #2 and Hospital #4. I have been told we (Regional Referral Hospital #1) do not accept patients from Hospital #4. So this is something to discuss with Hospital #2's Urologist." ED Physician #5 finished the telephone call with, "Okay, I just wanted to have this on record."

Referral Intake Record - Hospital #1
Review of RN #7's documentation on Regional Referral Hospital #1's referral intake record dated 07/04/2019 revealed, "Pt wants to come to Regional Referral Hospital #1. But pt(patient) will be referred to Hospital #2's Urology service. ED Physician #5 is put in contact with the on-call urologist at Hospital #2." On 07/04/2019 at 8:00 PM, RN #7 documented "4 mm(millimeter) stone with hydro(Hydronephrosis). Fever 102.7, 90 systolic, receiving IVFs(Intravenous Fluids) now. Rocephin after blood and urine. PMH(Past Medical History): Anemia, IBS(Irritable Bowel Syndrome), and Depression. Hospitalist to evaluate and then transfer to Hospital #2 to OR(Operating Room) for STENT. Call MD(Medical Doctor) when pt leaves Hospital #4(transferring hospital)." ED Physician #5 was told by on-call Urologist #3 that the patient would need to be admitted through the hospitalist service at Hospital #2. Hospitalist MD #2 for Hospital #2 calls the referral line and speaks with ED Physician #5 from Hospital #4. RN #7 documented "Hospital #4's hospitalist will need to do all the admission paperwork to transfer pt to Hospital #2 per Hospitalist MD #2". At this point, ED Physician #5 from Hospital #4 contacted Hospitalist #4 at Hospital #2 to complete the patient's admission paperwork. On 07/04/2019 at 8:52 PM, Hospitalist #4 contacted the referral line at Regional Referral Hospital #1 to speak with Hospitalist MD #2 about the need for the hospitalist to hospitalist transfer of the patient. On 7/04/2019 at 9:02 PM, Hospitalist MD #2 calls the referral line to accept patient. The intake note from RN #7 at 9:02 PM, reads, "Pt is septic, Receiving 3rd(third) liter of NS at this time. BP 85 systolic. Pt needs ICU(Intensive Care Unit). Needs central line and Levophed. Dx:(Diagnosis) Obstructing stones, sepsis and Hydronephrosis." On 07/04/2019 at 9:22 PM, the referral line at Regional Referral Hospital #1 contacted Hospitalist MD #2 to inform Hospitalist MD #2 that at 9:17 PM transportation was dispatched to pick up the patient from Hospital #4. Hospitalist MD #2 completed the History and Physical on 07/04/2019 at 9:44 PM at Hospital #2.

Bed Census Hospital #1
Review of Regional Referral Hospital #1's Bed Census report for 07/04/2019 revealed the Medical Intensive Care Unit (ICU) had a patient census of 24 with available beds at 29. Five (5) ICU beds were open and available. The Regional Referral Hospital had the capacity to provide the services for Patient #11 when the request was made for transfer from Hospital #4.

Urology On-Call schedule- Community Call - Hospital #1
The hospital's July 2019 On-Call Urology schedule for Regional Referral Hospital #1 was reviewed. The on-call schedule verified that on July 4, 2019, that PA #1 was listed as first call, and there was a Urology physician listed as second call (7a-7p) when the request was made to transfer Patient #11. The Regional Referral Hospital #1 had the Capability to accept Patient #11 on July 4, 2019.

Regional Referral Hospital #1's refusal to accept Patient #11 related to the hospital's on-call procedure for Urology that requires any patient presenting to Hospital #4 requiring higher level medical services from Urology must be transferred to Hospital #2 necessitated ED Physician #5 from Hospital #4(transferring hospital) to make repeated telephone call requests to the Regional Referral Hospital #1's referral line seeking admission for Patient #11. The Regional Referral Hospital #1's referral center is responsible for facilitating transfers and admissions for all three hospitals. The referral line is staffed by registered nurses. The nurses contact the appropriate physician for admitting and transferring of patients at seven area hospitals in the Hospital System. The two major Urology groups in the area have a verbal agreement to only admit to urology patients to Hospital #2. The Regional Referral Hospital's failure to accept the transfer of Patient #11 on July 4, 2019 had a delay in stabilization and treatment resulting from the necessity of incurring 15 telephone calls to the Regional Referral Hospital #1's referral line to get Patient #11 to Hospital #2 when Regional Referral Hospital #1 had the capability and capacity to treat the patient and the patient requested specifically to go to Regional Referral Hospital #1.

Interview with Regional Referral Hospital #1's Referral Manager #3
On 01/28/2020 at 2:50 PM, a face to face interview was conducted in the ED conference room with Referral Line Manager #3. During the interview, Referral Line Manager #3 stated he/she oversees Regional Referral Hospital #1's referral line and bed management department. Manager #3 explained, "We are able to document patient name, date of birth, medical record number, and we also include emergent or non-emergent transfer. With the system, telemetric, we can call directly or send page for MD to call referral center. Once the physician calls back, the physicians are placed on a three way phone line, which includes the referral RN, to communicate about the needs of the patient. Once accepted to the facility, the call ends and the referral center will arrange the transportation. This system has been in place for 10 to 15 years and is an established practice." When asked if the staff in the referral and bed management area has had Emergency Medical Treatment and and Labor Act (EMTALA) training, Manager #3 stated, "I have not had EMTALA training and my staff has not been trained in EMTALA."

Interview with RN #7 Referral Line Nurse Hospital #1
On 01/30/2020 at 7:40 AM, a face to face interview was done in the main conference room with RN #7 who verified that he/she works in the referral center. RN #7 reported, "I will contact whoever is indicated and let them talk. The two physicians talk and decide if the patient will be transferred. It does depend on where they are calling from and the specialty." RN #7 explained the process for a patient needing urology coming from Hospital #4 when the patient requiring transfer from Hospital #4 had to go to Hospital #2." When asked what happens if Regional Referral Hospital #1 has capability and capacity to treat the patient, and the patient requests a transfer to Regional Referral Hospital #1, RN #7 stated, "In that case, Regional Referral Hospital #1 is covered by another Urology Group or Hospital #2's Urology Group." When asked to see a copy of the policy, Manager #3 explained, "The process is shared by word of mouth. If they (urology patients) are at Hospital #4, they are referred to Hospital #2. This is the agreement Regional Referral Hospital #1, Urology Group, and Hospital #2's Urologists have established."

Interview with Bed Management Manager Hospital #1
On 01/30/2020 at 9:30 AM, the Bed Management Manager was interviewed face to face in the Bed Management conference room, and verified staff received EMTALA training during the week of 1/27/2020, but had not had any education on EMTALA prior to the survey. When asked if any changes in their practice would occur as a result of EMTALA training, the staff replied, "I don't think so."

Physician Assistant(PA) #1 with Urology Group at Regional Referral Hospital #1 Interview
On 01/30/2020 at 8:50 AM, a face to face interview was conducted with PA #1 in the main conference room. When asked if PA #1 had any training on EMTALA, PA #1 replied, "I don't believe I have had any." PA #1 described the process for a patient wanting to come to Regional Referral Hospital #1 from Hospital #4 as "It is our practice protocol for them(patients) to transfer to Hospital #2." PA #1 stated, "I believe the practice protocol is written. You would have to ask our Chief of Urology."

Interview with Chief of Urology at Regional Referral Hospital #1
On 01/30/2020 at 12:00 PM, a face to face interview with the Chief of Urology in the main conference room revealed the Chief of Urology verified that he has had some EMTALA training, and explained, "We do computer based training for this." The Chief of Urology described the process for the Urology on-call practice protocol as "The agreement we have with Urologists at Hospital #4 is: If there is a need at Hospital #2 or Hospital #4, Hospital #2's group covers. Regional Referral Hospital #1's Urology group covers the other hospitals. If a patient asks for Regional Referral Hospital #1, we set it up where the Urologist from Hospital #4 contacts Urology from Regional Referral Hospital #1 to make that decision. They do manage patients with septic stones ...that can be managed in either hospital."

Urology Group's Meeting Minutes
Review of the meeting minutes for the Urology Physicians Meeting dated January 28, 2019 revealed an entry about the Western/Central Transfer Communication for patients requiring transfer, and states, "Advised that for patients from either region who may need transfer, that respective provider needs to be contacted to discuss situation. Western providers answering calls from Hospital #4 and Hospital #2 and can re-route pt.(patient) if needs Regional Referral Hospital #1's management."

Regional Referral Hospital #1's refusal to accept Patient #11 related to the hospital's on-call procedure for Urology that requires any patient from presenting to Hospital #4 requiring higher level medical services from Urology must be transferred to Hospital #2 necessitated ED Physician #5 from Hospital #4(transferring hospital) to make repeated telephone call requests to Regional Referral Hospital #1's referral line seeking admission for Patient #11. Regional Referral Hospital #1's referral center is responsible for facilitating transfers and admissions for all three hospitals. The referral line is staffed by registered nurses. The nurses contact the appropriate physician for admitting and transferring of patients at seven area hospitals in the Hospital System. The two major Urology groups in the area have a verbal agreement to only admit urology patients to Hospital #2. The hospital ' s failure to accept the transfer of Patient #11 on July 4, 2019 had a delay in stabilization and treatment resulting from the necessity of incurring 15 telephone calls to Hospital #1's referral line to get Patient #11 transferred to Hospital #2 when Regional Referral Hospital #1 had the capability and capacity to treat the patient and the patient requested specifically to go to Regional Referral Hospital #1.

Hospital #1's Policy and Procedures.
Hospital Policy, titled "Transferring and Accepting Patients from another Facility, Including a Health-Upstate Hospital (S-050-168), Approved 2/14/2018, and Effective 10/1/2019. Policy 3.1", states in part, "A physician from the referring facility should contact the Referral Center to facilitate a patient transfer. Referral Center staff will contact the physician and coordinate communication with the referring physician."
Policy 3.2, reads, "Physicians requesting to transfer a patient for specialized services from the Emergency Department will be referred to the physician on duty in the Emergency Department to facilitate the transfer if an accepting physician has not been identified."

Hospital policy, titled, "Greenville Health System Medical Staff Policy on Emergency Services (EMTALA) On-Call Physicians, Approved by the Board of Directors July 11, 2017 was reviewed. The policy revealed in part, "XV1, Policy: ACCEPTANCE OF ED TRANSFER FROM OTHER HOSPITALS (RECIPIENT HOSPITAL RESPONSIBILITIES): IF GHS Hospital has specialized/capabilities/facilities (physician, staff, equipment, etc.) and capacity (bed space) at the moment of the request, GHS hospital ED personnel and on-call ED staff may not refuse to accept an appropriate transfer of an unstable ED patient from another hospital's ED within the boundaries of the United States."