HospitalInspections.org

Based on findings at A2406, the facility failed to ensure compliance with Code of Federal Regulations (CFR) 489.24.

Based on record review, interview and document review, the facility failed to ensure a patient was provided an appropriate medical screening prior to transfer to a psychiatric facility (Patient #30).

Findings include:

Patient #30 (P30)

P30 presented to the Emergency Department (ED) on 12/04/17, for complaint of leg pain and cramps.

The ED Triage note, dated 12/04/17, documented the patient arrived at the ED via ambulance at 7:59 AM with leg cramps for one hour. The patient had been shouting and grimacing in the Emergency Department lobby. The patient had rated pain as "10" using a 0-10 pain scale, with 0 indicating no pain and 10 indicating severe pain. The note documented the patient's reason for visit had been leg pain.

The ED Physician Note, dated 12/04/17 at 8:33 AM, documented the patient presented with lower extremity pain, onset had been an hour before arrival to ED, and had been gradual, course/duration of symptoms had been constant. The patient denied any injury to the lower extremity. The character of symptoms had been cramping, degree had been moderate. There had been no relieving factor. The patient had been complaining of bilateral leg cramps for one hour, had denied any history of the condition, and was not a good historian. The patient indicated not having any medical or mental history.

The Review of Systems revealed there was no fever or chills, no shortness of breath, no cough, no chest pain, no abdominal pain, no nausea, no vomiting, all other systems reviewed and otherwise negative, other than noted above.

The Physician's Physical Examination included the patient had been alert, agitated and restless. The patient's skin had been warm and dry. The patient's head, neck, eyes, ears, nose, mouth, and throat had been examined. Cardiovascular with regular rate and rhythm, respiratory lungs had been clear, respirations were non-labored, breath sounds equal, gastrointestinal soft, nontender, nondistended and neurological normal speech had been observed, cognitive function oriented x 3 to person, place and time.

The clinical impression was acute psychosis and elevated blood pressure reading. The patient's condition was guarded, the patient was medically cleared and transitioned to psychiatry on 12/04/17 at 11:17 AM.

The Nursing Assessment, dated 12/04/17 at 8:55 AM, documented the patient was awake, alert and oriented times three. The patient had clear bilateral breath sounds, normal sinus rhythm, skin was warm and dry with normal color, bilateral dorsalis pedal pulses were normal, capillary refill was instantaneous, bilateral motor strength was normal (5/5) for both upper and lower extremities, bilateral upper and lower sensation was normal, gait was steady and abdomen was soft and non-distended.

The Nursing Note and Flow Sheet Print Request form, dated 12/04/17, documented the following:
-9:20 AM, documented the patient was squirming in bed. Skin is warm and pink.
-10:10 AM, documented the patient's skin was warm and pink. Radial pulse is plus. Patient keeps getting out of bed and throwing self on floor. Stressed importance in staying on monitor and not getting up due to chance of falling.
-11:43 AM, documented lunch coverage, patient in bed and reports, "my legs feel hard," patient anxious and Registered Nurse (RN) unable to reason with patient. Respirations even and unlabored, skin warm and dry. There was no documented evidence in the record the physician was notified.
-11:58 AM, documented the patient was placed on an involuntary legal hold for inability to care for self.

A Social Work Note, dated 12/04/17 at 11:17 AM, documented the patient presented to the ED with complaints of leg pain. Patient was being disruptive in the lobby and her behavior continued in the ED. Patient was throwing self on the floor screaming. When I went to speak with patient, patient had already received pain meds, Haldol, Ativan, and Valium. I introduced self myself to patient and explained to patient it was my understanding that patient had children. Patient reported having 9-year old twins who attended elementary school. Patient reported friends would pick up the kids but was unable to say for sure if friends were on the approved school pick up list. Patient denied having any family in tow. When asked about how long patient had been in town, patient became agitated and yelled, "I'm trying to buy a house." Patient kept rubbing head, closing eyes and rubbing legs. The patient kept complaining of leg pain but was unable to articulate how it felt and what it felt like. Spoke with ED physician who believes he would be placing the patient on an Legal 2000 (L2K/involuntary legal hold). Called Child Protective Services with patient's information and concerns regarding the safety of the children.

The Application, Certification, and Medical Clearance For Emergency Admission of an Allegedly Mentally Ill Person to a Mental Health Facility (Legal 2000 Hold) form documented the patient was placed on an involuntary legal psychiatric hold on 12/04/17 at 11:58 AM, due to "Patient is very agitated and frequently throwing self on floor. Patient speech is incoherent and erratic. I have concerns that patient does not have the where with all to care for basic needs." The involuntary hold was initiated by the Registered Nurse. The physician medically cleared the patient on 12/04/17 at 12:00 PM. The physician certified the patient was agitated and unable to care for self on 12/04/17 at 12:00 PM.

The Physician Adult ER (Emergency Room) Report, dated 12/04/17 at 11:17 AM, documented the following:
History of Present Illness: P30 arrived by ambulance, screaming out that legs were cramping and needed help, was inconsolable. P30 initially got Norco and 10 of Valium, and the patient calmed down some. P30 denied any health problems, denied ever having been like this before and denied any mental health problems. P30's story varies. P30 received 10 of Haldol and 2 of Ativan, and had finally calmed. The patient told me bought a house, moving to Georgia tomorrow. The patient told the social worker a different story. The patient denied any trauma, no history of blood clots. The patient stated living alone with kid. The patient had plural kids. When asked about how old they were, the patient said 9. The patient stated the kids were currently in school. The patient stated that nobody could come and pick the patient up. The patient did not have any friends that could be contacted, but claimed that friends were going to pick the kids up from school. The patient was acting like one should have psychosis or bipolar or schizophrenic, although patient denied a history of that.

The Physical Exam revealed the patient's hygiene was pretty poor. Head was traumatic, oropharynx was very dry and lips were chapped and cracked. Extremities with no significant edema, had full strength in all extremities, the patient threw self on the ground a couple of times, did not seem to hurt self. The patient was going to the sink to drink out of the faucet multiple times, ripped out the IV, and had been placed on Legal 2000 (involuntary psychiatric hold) and was medically cleared at this time.

The Psychiatrist Final Report, dated 12/04/17 at 2:25 PM, documented the patient arrived at the hospital by ambulance screaming that legs were cramping and needed help. The patient was inconsolable. The patient was administered multiple medications including Norco, Valium, Haldol, Ativan and finally regained control. The patient apparently threw self on the floor screaming uncontrollably. Upon face to face evaluation by the Psychiatrist, the patient was sedated. The patient was unable to be aroused to answer questions appropriately. The patient was unable to explain the reason for being in the ED, stating "I can not talk now." The Psychiatrist was unable to obtain a past psychiatric history. The past medical history included urinary tract infection and leg pain. The Psychiatrist was unable to obtain a social history or substance use history from the patient. The patient's laboratory documented urine drug screen was negative and alcohol was negative. The physical examination revealed an elevated blood pressure at 152/64, heart rate 89, respirations 20, and oxygen saturation 98% on room air. The Mental Status Exam indicated the patient appeared to be stated age, unkept in hospital gown. The patient had been uncooperative during the interview, had poor eye contact, and was unable to be assessed for mood, thought process and thought content due to drowsiness. The patient's affect had been drowsy. The Psychiatrist diagnosed the patient with a brief psychotic episode; rule out underlying psychiatric illness and urinary tract infection. The plan included to continue legal 2000 hold for now as the the Psychiatrist was unable to garner a full psychiatric evaluation at that time; would order Zyprexa 5 milligrams at bedtime for agitation; recommend limiting narcotics; monitor psychotic symptoms for now; recommend transfer to inpatient psychiatric facility, until patient could be evaluated fully.

The Nursing Notes and Flow Sheet Print Request Form dated 12/04/17, documented the following:
1:00 PM- the patient was observed calm.
1:15 PM- the patient was observed calm.
1:30 PM- the patient was observed calm.
1:45 PM- the patient was observed calm.
2:00 PM- documented the patient was resting, no changes noted.
4:00 PM- documented the patient resting, no changes noted, patient reassured.
5:15 PM- the patient was observed calm.
5:30 PM- the patient was observed calm.
5:45 PM- the patient was observed calm.
6:00 PM- documented the patient ate dinner, no changes noted.
6:30 PM- the patient was observed asleep.
6:45 PM- the patient was observed asleep.
7:00 PM- the patient was observed asleep.
7:15 PM- the patient was observed asleep.
7:25 PM- documented no acute distress, patient calm and cooperative.
7:30 PM- the patient was observed calm.
8:00 PM- the patient was observed calm.
8:30 PM- the patient was observed calm.
9:00 PM- documented patient feeling better.
9:28 PM- documented gait steady.
9:45 PM- documented patient awake, up to bedside commode with no assistance, patient calm and cooperative.

The BHU Suicide/Self-Harm Assessment, dated 12/04/17 at 8:54 PM, documented the patient had no suicide attempts, no elopement risk, no plans to commit suicide, no previous attempts at suicide. Suicide/Self Harm Score had been zero. The patient had been impulsive with impaired problem solving. The assessment documented the Registered Nurse indicated the patient's replies had been trustworthy and reliable.

The Patient Transfer Sheet, dated 12/04/17 8:00 AM to 9:30 PM, documented the following medications given in the ED:
Percocet 10/325 mg (milligrams) by oral route at 8:24 AM.
Valium 10 mg by oral route at 8:24 AM.
Haldol 5 mg intramuscular injection at 9:18 AM and 10:21 AM.
Ativan 2 mg intramuscular injection at 10:21 AM.
0.9 Normal Saline (NS) at 2 liters at 8:53 PM; 0.9 NS 1 liter by intravenous route at 9:18 AM.
Ibuprofen 400 mg by oral route for fever at 7:55 PM.
Rocephin 2,000 mg by intravenous route at 8:53 PM.
Levaquin 750 mg by oral route at 8:53 PM.
Zyprexa (antipsychotic) 5 milligrams (mg) by oral route at 8:53 PM.

Authorization for Transfer, dated 12/04/17 at 9:45 PM, documented the patient had been accepted for transfer at an inpatient Psychiatric hospital and the patient did not suffer from an emergency medical condition. Expected benefits of transfer included continued care at an appropriate medical facility and a need for specialized care.

There was no documented evidence pedal pulses were reassessed after the initial assessment, even after the patient was complaining of leg issues at 11:43 AM.

The ED Discharge Note, dated 12/04/17 at 10:00 PM, documented the patient had been transferred to a Mental Health Facility.

On 2/21/19 at 10:40 AM, a Quality Management Registered Nurse (RN) confirmed there were no pain level assessments done between the initial one at 8:03 AM and the one before transfer at 9:45 PM on 12/4/18. There was no diagnostic radiology done because the Physician and nurse(s) thought the patient had a mental health issue, not a pain issue.

On 2/22/19 at approximately 12:00 PM, the Emergency Department Medical Director indicated the clinicians did not feel a need to reassess pedal pulses because they were normal upon initial assessment. Diagnostic testing was not always ordered in these situations and depended upon a number of other variables.

An interview with an Emergency Room Physician on a previous investigation revealed if a patient presented to the Emergency Room (ER) with a chief complaint of leg pain and cramping, the Physicians would make an assessment to check the patient's extremities, provide pain medications to manage the patient's symptoms and perform testing such as blood work, Computed Tomography test, ultrasound to rule out the possibility of a blood clot. The Physicians would question the patient if there had been a recent trauma or injury to the extremities. The Physicians would find the cause of the problem. Physician #1 indicated time was of the essence in dealing with patients with a possible blood clot. It would be important for a Physician to realize that time is a critical factor and the patient must be treated promptly. If the patient's complaints were ignored, and if the patient turned out to have a blood clot in their legs, the patient could end up losing their leg if prompt attention was not provided in the Emergency Department.

An interview with another Emergency Room Physician on a previous investigation revealed if a patient presented to the Emergency Room with complaints of leg pain and cramping, the Physician would perform medical screening, obtain history and conduct a physical assessment of the patient. The Physician could then order blood work, an X-ray, a Doppler ultrasound to be able to conclude the patient was medically cleared. Psychotic issues could arise if a patient had severe pain. Regardless if the patient had behaviors during the course of the stay in the ER, the patient's medical concerns and chief complaint of leg pain and cramping would still need to be examined to determine where the pain had been coming from.

On 2/27/19 at 3:23 PM, the Registered Nurse who performed the initial ED screening and who was assigned to the patient until 11:00 AM on 12/4/19, indicated patients should be reassessed within an hour of pain medication administration and every two hours. Patients should be reassessed for pain with each set of vital signs. The patient was not reassessed for pedal pulses because there were no significant changes which warranted reassessment. The patient verbalizing the legs felt hard (at 11:43 AM) did not sound substantially different from what the patient had verbalized earlier. Diagnostic radiology was not ordered for every patient in the ED. The patient was not communicative enough. The Physician decided whether or not to order any diagnostic radiology. Vessel occlusion typically developed gradually over a period of time. Radiology and ultrasound may have identified whether or not the patient had a thrombus, deep vein thrombosis or blood clot. Other conditions could mimic the patient's symptoms of bilateral leg pain, like peripheral neuropathy or back pain. The patient threw self on the floor about every 5 minutes for the first couple hours and became more calm the last hour of the nurse's assignment (8:00 AM to 11:00 AM).

The ED Physician Note, dated 12/06/17 at 12:41 PM, documented the patient presented to the ED with worsening symptoms of bilateral lower extremity leg numbness and paresthesia. The patient had been seen at the same ED two days ago on 12/04/17 for bilateral leg cramping and had been placed on Legal 2000 for abnormal behavior. Physical Examination of the patient included bilateral lower extremities had been cool to touch with mild cyanosis, arterial pulses bilateral posterior tibial and pedal pulses were absent, bilateral calf swelling, decreased sensation to bilateral lower extremities. The patient had been alert and oriented to person, place and time. The patient had been diagnosed with acute aortic arterial occlusion of the lower extremities and had been recommended for urgent vascular surgery consultation. The patient was admitted to the Intensive Care Unit due to a critical condition.

The Intensive Care Unit History and Physical, dated 12/06/17 at 2:59 PM, documented the patient had been admitted for intensive monitoring of critical condition including bilateral ischemia (an inadequate blood supply to a body part) of the lower extremities and severe arterial thrombosis (blood clot) in the aorta. The patient had pain and weakness for the last two days and had been transferred from the Psychiatric facility to the ED due to bilateral cold legs and absence of peripheral pulses. The patient's Computed Tomography scan revealed extensive intra-arterial thrombus involving the abdominal aorta and left iliac artery. The thrombus in the entire abdominal aorta had 50-60% stenosis, and 80% stenosis in the celiac axis.

A Post-Operative note, dated 12/06/17 at 5:40 PM, revealed the patient had a surgical procedure for bilateral thrombectomy (surgical procedure to remove a blood clot) and fasciotomy (surgical procedure to remove pressure or tension to treat the resulting loss of circulation to a tissue or muscle).

An Operative Report, dated 12/06/17 at 5:49 PM, documented the patient presented to the ED complaining of bilateral leg cramps. The patient had been admitted for a Psychiatric evaluation and transferred to a Psychiatric hospital. The patient's conditioned worsened over the next 12 hours, and the patient was transferred back to the ED with pulseless, cold lower extremities. The patient underwent diagnostic testing which revealed significant thrombus beginning in the distal aorta and extending into the left common iliac, bilateral femoral arteries and into the popliteal arteries.

A Post-Operative note, dated 12/07/17, revealed the patient had another surgical procedure for left lower extremity thrombectomy due to ischemia and a left femoral to below the knee popliteal artery bypass.

A Consultation Report, dated 12/09/17, documented the patient had been admitted for pain in the legs and had been initially worked up for psychiatric illness because of the patient's severe reaction to complaints which had been misinterpreted.

The facility policy Legal 2000 (L2K) Patient Assessment and Monitoring, dated February 2017, documented appropriate and necessary medical and nursing interventions would supersede all behavioral health activities to ensure the stability of the patient. Any L2K patient with medical needs would be admitted to the appropriate in-patient nursing unit for further monitoring, care and interventions. The Licensed Independent Practitioner would perform a medical screening exam to determine medical clearance for a psychiatric evaluation. After the patient had been medically cleared and placed on a L2K Hold, the Psychiatric Consultant would be contacted for mental status examination and further determination of course of care.

The facility policy Legal 2000 (L2K) Patient Hold Process, dated July 2018, documented if after the examination, the Licensed Independent Practitioner (LIP) deemed there was no medical condition that would require hospitalization, the LIP would be responsible for medically clearing the patient and evaluating whether the patient would be likely to harm themselves or others. Medical clearance defined as the process performed by a LIP to ensure the L2K patient meets the criteria of having "no medical disorder or disease other than a psychiatric problem that requires hospitalization or treatment." The LIP would initiate diagnostic testing to determine medical clearance.

The facility policy Pain and Comfort Management, dated July 2018, documented pain and comfort assessment and reassessment would be performed and documented after every pain and/or discomfort relieving intervention. Adult patients would be reassessed within one hour of intervention, comparing current pain intensity level to acceptable pain intensity level goal and evaluating for analgesic side effects. Reassessment would include current pain intensity level and whether interventions were effective. Pain and comfort assessment and reassessment data would include, but not limited to history, location, onset, duration, pattern, alleviating and aggravating factors, and present pain management. All assessments, reassessments and intervention would be documented in the patient's health record.
Patient rights to pain management included the right for appropriate assessment of pain on admission and throughout the hospital stay. A patient's report of pain would be believed and taken seriously. The patient had a right to healthcare professionals who would respond quickly to reports of pain.

Complaint #NV00056119