HospitalInspections.org

Based on findings at A2406, the facility failed to ensure compliance with CFR 489.24.

Based on observation, interview, record review, and document review, the facility failed to provide a complete and appropriate medical screening exam for 3 of 41 patients sampled: 1 patient who was found rolling on the ground on hospital property (Patient #17) and 2 patients (#21 and #8) who presented with psychiatric complaints.

Findings include:

Patient #17

Record Review

Patient #17 was a 57 year old male who presented to the Emergency Department on 01/16/10 at 11:47AM, with a chief complaint of weakness and laceration. The patient complained of general body weakness and stated he fell and hit the back of his head.

The triage nurse documented the patient fell and hit his head on the cement sustaining a laceration to the back of his head. The patient was confused at this time. The patient was previously seen in the Emergency Department on 01/15/10 and was discharged home. The patient was also complaining of weakness and abdominal pain. The patient arrived in the Emergency Department via wheelchair. The patient ' s pain rating was a 4, vital signs were stable, and the patient had a past medical history positive for congestive heart failure, diabetes, and primary biliary cirrhosis. The patient had a social history that was positive for tobacco, alcohol and drug (crack) use. Patient #17 was triaged as a level III.

The nursing assessment documented the patient was positive for weakness and a laceration.

The Emergency Department physician assessment completed on 01/16/10 at 1:17PM, documented the chief complaint was a head laceration and blunt trauma. The patient had lost his balance, fell, and hit his head. There was no loss of consciousness and the severity of his symptoms was mild. The patient complained of a headache. Examination of the patient ' s head revealed a hematoma, abrasion, laceration and swelling located on the back of patient's head. The patient was positive for icterus. The patient's abdomen was soft. The patient was alert and oriented times three. Computer tomography scan of the head was within normal limits. The clinical impression was a closed head injury. The head laceration was cleaned and 2 staples used to close the wound.

The Emergency Department record revealed an emergency medical condition did not exist and the patient was ready for discharge on 01/16/10 at 1:22PM. The patient was discharged with instructions to follow up with a primary care physician in 7 days.

Document Review

1. Hospital security documented on 01/16/10 at approximately 11:15AM, security was called to assist a white male adult (Patient #17) who was found on the ground between the hospital and the bus stop drive way. The patient was bleeding on his head and security called Emergency Department staff, which immediately arrived and transported the patient to the Emergency Department for treatment.

2. Hospital security documented on 01/16/10 at 5:30PM, Patient #17 was advised that he had been discharged and needed to leave the hospital grounds. The patient acknowledged the information, but refused to leave the hospital property. Patient was again advised that he needed to leave the hospital property. The patient continued to be uncooperative. Security informed the patient that if he continued to be uncooperative, he would be trespassed. The patient did not make an attempt to move. At this point, security called the police department (non-emergency) for a trespass escort. Security went back to inform the patient he was being trespassed and the patient continued to remain lying down on the Emergency Department bench.

Hospital security documented on 01/16/10 at 6:05PM, the police sergeant was advised that hospital security was able to forcibly escort the patient to the bus stop and he had been officially trespassed. The next time the patient came on to the hospital property, he would be arrested.

Hospital security documented on 01/16/10 at 7:40PM, " subject now rolling around on ground behind bus stop. Notified police as individual was creating traffic hazard to hospital personnel arriving/departing for/from work. Security Officer (name) waited with subject. Police attempted to get subject to stand. Uncooperative they legalled him and called for ambulance to transport to another facility. "

Side Note: " Just after subject was escorted to bus stop, he defecated on bench in public. He then walked over to sidewalk and sat down. At about 7:00PM, ambulance staged at the area. He was asked if wanted to go somewhere by ambulance, he refused and said he wanted to go to bus station. Prior to this, Security Officer (name) had also given him money for bus fare. The 7:40PM call was prompted by his obstructing traffic. "

3. Police report dated 2/23/10, documented, " On 1-16-10 at 1954 (7:54PM) Officer (name/badge number) and I responded to the bus stop in front of (name of hospital) at 1409 Lake Mead Boulevard East in reference to a white male adult (WMA) rolling around on the ground in front of oncoming traffic.

Upon arrival, I contacted a WMA, identified as (Patient #17), laying on the ground behind the bus stop. I asked (Patient #17) why he was laying on the ground, but he would not respond to my question. (Patient #17) asked for my help to stand up. When I attempted to help him, he yelled as if in pain and laid back down. (Patient #17) claimed he was unable to stand or walk on his own. (Patient #17) told me he was homeless, but just mumbled incoherently when I questioned him further.

I contacted the person reporting, identified as (hospital) security guard (name). (Security Officer) told me that earlier today he had given (Patient #17) money for the bus. Later while making his rounds near the bus stop, he saw (Patient #17) rolling around in the street (Lake Mead Boulevard East) in front of oncoming traffic. He said (Patient #17) was nearly struck by vehicles several times. Worried (Patient #17) would get hit by a car, he helped (Patient #17) out of the street and called the police.

Due to (Patient #17) acting in a manner in which a reasonable probability for serious bodily injury or death existed, I called for medical personnel to respond for a Legal 2000.

Ambulance arrived and transported (Patient #17) to another hospital for treatment. "

4. The Director of Risk Management provided a map of the facility, in which it was indicated the area behind the bus stop and in front of the physician parking area was considered hospital property.

Interview

1. On 03/09/10 at 5:10PM, interview with Security Officer on duty from 6:00AM to 2:30PM on 01/16/10, revealed he was called by the Emergency Department staff, because the patient did not want to leave. The Security Officer escorted the patient off hospital property and took him to the bus stop. The patient was walking straight and sat on the bench at the bus stop. The patient was very cooperative and the Security Officer explained to the patient the consequences for not leaving the premises and he would be trespassed. The Security Officer left the patient seated at the bus stop.

2. On 03/10/10 at 2:00PM, interview with Security Officer on duty from 6:00PM to 2:30AM on 1/16/10, revealed he escorted the patient to the bus stop. The patient wanted to go to the bus station and the security officer provided the patient with bus fare. The Security Officer was called out behind the bus stop. There was an ambulance there, as the area behind the bus stop was a staging area for ambulances, the patient was sitting next to the bus stop. Security then received a call from nursing indicating the patient was blocking the road and they could not get off the property. The police was called and tried to put the patient into their car with no success. The Security Officer indicated the patient did not complaint of any pain.

3. On 03/10/10 at 3:45PM, interview with Security Officer on duty from 2:00PM to 10:30PM on 01/16/10, revealed Patient #17 had been discharged from the Emergency Department. The Security Officer reported the patient had assumed a sleeping position in the waiting room. The patient was informed three times he had been discharged and needed to leave the hospital premises. The patient was informed if he did not leave; the police would be called because the patient was now trespassing on hospital property. The patient still would not leave. When the police sergeant arrived, the patient left the waiting room and walked toward the bus stop. About an hour later, security received a call indicating the patient was still on the grounds. The patient was escorted back to the bus stop, and he seated the patient down at the bus stop. Security witnessed the patient defecate at the bus stop. A while later, security received a call, the patient was lying behind the bus stop rolling around on the ground causing a traffic obstruction. The police was called. The Security Officer indicated the patient refused to get up and refused assistance. When the police arrived, the patient refused to follow their orders. The police officer called his supervisor and was advised to call 911 and take the patient to another facility, due to the patient had been trespassed at the hospital. The Security Officer reported the patient was rolling around on the ground; he voiced no complaints, and refused to stand to be escorted back to the bus stop. The Security Officer reported the patient was on the ground behind the bus stop in the drive thru area in back of the bus stop, which he stated was not on hospital property.

The patient was found rolling around on the ground causing a traffic obstruction on hospital property by hospital security guards. The patient was not assisted to the hospital emergency department for a medical screening exam as was done earlier in the day, when the patient was found on the ground. There was no documented evidence the patient was logged into the Emergency Department for a medical screening evaluation after he was found rolling around on the ground.
The patient was transported to the Emergency Department of another local hospital. The Emergency Department Admit note dated 01/16/10 documented, the patient had some abrasions on his head. The right leg was shortened and internally rotated with pain on palpation of the right hip. Diagnostic studies showed the patient had a right intratrochanteric hip fracture. There was a large left pleural effusion. CT (Computerized Tomography) scan of the brain showed a small left-sided subdural hemorrhage involving the left temporal lob, extending into the left frontal parietal regions. There was also a small subdural posterior and a small intraparenchymal bleed verus calcification. The clinical impression was subdural hematoma, right intratrochanteric fracture, cirrhosis, thrombocytopenia, coagulapathy, and altered mental status. The Discharge Summary dated 1/20/10 documented, the patient was "amnestic on arrival" to the Emergency Department. The initial workup revealed "a subdural hemorrhage as well as coagulapathy secondary to cirrhosis. Patient was jaundiced with scleral icterus. He also has a large left pleural effusion and a right comminuted hip fracture. Further workup revealed renal insufficiency, hepatitis C, free fluid in the abdomen as well as a right testicular mass. Trauma service was consulted at this point and patient was admitted to Trauma ICU (Intensive Care Unit)." The patient was admitted to the hospital on 1/16/10 and expired on 1/20/10.

Observation

On 3/10/10 in the morning, the area where Patient #17 was reported rolling around on the ground "behind the bus stop" was a driveway area. This driveway was used as a thruway connecting to the drive and parking lot for the hospital physician's garage and staff parking lot which also connected to the drive leading to patient/visitor/valet parking and the front of the hospital. This areas was all delineated by the Risk Manager on the facility's map as being on hospital property. Cars were observed driving back and forth, to and from the direction of the front of the hospital and continuing behind the bus stop and around to the garage or parking lot and vice versa.

Patient #21

Record Review

Patient #21 was a 64 year old male who presented to the Emergency Department (ED) on 02/03/10 at 4:24PM, with a chief complaint of intoxication.

The patient was triaged on 02/03/10 at 4:24PM. The patient was brought to the Emergency Department via ambulance and stated "he has been drinking alot of alcohol today to 'drown his sorrow' and he wants to go back to the war to kill people." There was no treatment provided by Emergency Medical Services prior to arrival to the Emergency Department. The patient was not in any pain, medications included Tramadol and Omeprazole. The patient had a past medical history positive for alcoholism and post traumatic stress disorder. The patient lived alone and used tobacco and alcohol. Initial vital signs were stable. Patient #21 was a triage level II.

The initial nursing assessment documented the patient was depressed, had delusions, hallucinations, homicidal ideations and suicidal ideations. A referral for behavioral health was completed.

The Suicide Risk Screening form documented the patient was not seen in the ED secondary to a recent suicide attempt. The patient did not have any suicidal ideations and there was no plan identified. The patient did not have a past history of suicide attempts or a family history of suicide. The patient had not been getting his affairs in order and did not have a recent impending major loss. The patient had Major Depression and an Addiction to alcohol or drugs. The patient did not have a history or recently exhibited dangerous or self-destructive behavior. A psychiatric evaluation was ordered on 02/03/10 at 6:12PM.

The ED physician evaluated the patient on 2/3/10 at 4:31PM. The chief complaint was depression, hallucinations, and homicidal ideation. The patient presented to the ED stating "that when he sees people that he believes they are Vietnamese and that the wants to kill them. Patient states he was non-compliant with psychiatric medications. Patient admits to drinking ETOH (alcohol) today. Denies SI (suicidal ideation)." The patient reported the symptoms started in the morning and he had experienced anger, agitation, and visual hallucinations. The patient was non-complaint with his medications. The patient had no support system. The patient was oriented x3 with emotional lability. Differential diagnosis included depression and acute psychosis. The patient's blood alcohol level was 229 (normal values 0-10mg/dL). The clinical impression was Homicidal Ideation and Acute Psychosis. The patient was medically cleared for psychiatric assessment. The patient's disposition was the EMC (Emergency Medical Condition) was stabilized, the patient was placed in observation, the medical condition was stable, and "follow up with Harmony Clinic today," ready for discharge on 2/3/10 at 7:00PM. The patient was evaluated by a Physician Assistant and reviewed by the ED physician.

The patient was placed on a Legal 2000 (Application, Certification and Medical Clearance for Emergency Admission of an Allegedly Mentally Ill Person to a Mental Health Facility) due to "Patient suicidal and homicidal ideation, patient has auditory and visual hallucination, patient non-complaint with medication, patient danger to self and others." This form was completed by a Registered Nurse. The patient was medically cleared for psychiatric evaluation on 2/3/10 at 8:10PM by the Emergency Department physician. The patient was certified that as a result of a mental illness this person was likely to harm self or others. The physician documented "Patient admits to thinking other people are Vietnamese and he wants to kill them. Also non-compliant with medications, unable to care for self." The certification was signed by the ED physician. There was no date or time documented.

The Physician Order Form: General Medicine dated 02/03/10, documented under Discharge Instructions "Homicidal Ideation and Psychosis."

The Emergency Department Visit Record documented the following:

- 2/3/10 at 9:56PM, Nurse Note: At 9:30PM (name) from (name of psychiatric evaluation agency) called for patient information and insurance identification number. Patient ETOH level was 229, patient had to be re-evaluated when alcohol level is lowered at 2:30AM, (name) from (name of psychiatric evaluation agency) will be calling for report from charge nurse at that time, charge nurse made aware.

- 2/4/10 at 10:22AM, Nursing Progress Notes: "10:00AM patient will be picked up by (name) from (name of psychiatric evaluation agency) and transfer to (name) Outpatient Clinic."

- 2/4/10 at 6:18PM, Discharge Instructions: "Follow up with (name) Clinic today at 1:30PM; Discharge Instructions: Depression."

Interview

On 03/09/10 at 3:00PM, the Emergency Department (ED) Director revealed the mental health agency completed the psychiatric evaluation. The ED Director reported there was no documented evidence in the medical record confirming the psychiatric evaluation and recommendations for treatment was completed. The ED Director was unable to explain why the patient was discharged to an outpatient clinic and not admitted to an in-patient psychiatric unit.

The medical record lacked documented evidence of a psychiatric evaluation ruling out an emergency medical condition and/or the stabilization of his homicidal ideation and psychosis and the discharge instructions were not signed by the patient or facility representatives. The patient was certified by the ED physician as being a danger to self and others and was discharged to a psychiatric outpatient clinic.




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Patient #8

This was a 44 year-old male who presented to the ER on 1/4/10 for a chief complaint of suicidal ideation.

The ER "Patient Check-In" form stated, "Reason for your visit" and "I want to kill myself !!!!!!" was the documented response.

The Nursing Documentation triage form indicated at 1656 - 1700 (4:56-5pm):

- the patient was ambulatory from home, oriented x4, and indicated the patient's chief complaint/reason for visit: "Suicidal ideation. 'Kicked out of house today' and is now a threat to others and himself. Ran out of psych meds 4 days ago and did not go to clinic. Plan is to slash his wrists."

- Medications : Ambien, pain medication for hips, Lexapro, and Risperdal.

- Past medical history: Bipolar and Depression.

- Social History: Lives alone, alcohol and tobacco was circled.

- Triage Category : II

The ER MD record: Medical Screening Evaluation indicated at 1745 (5:45pm):

- Chief Complaint: "Thrown out of group home"

- History of present Illness: "States he thinks he'll kill himself. No attempts nor self-injurious behavior."

- Onset: 2 h (hours) PTA (prior to arrival) Timing: persists

- Severity of symptoms: mild

- Exacerbating factors: "Out of meds"

- Alleviating factors: "none...Similar symptoms previously"

- Additional History: "Hospitalized @ (psych facility) last wk; cannot explain what happened to meds."

- Past Medical History: "Bipolar, Depression"

The MD indicated the same medications as triage nursing.

The Review of Systrems was conducted and virtually found to be normal. The boxes checked were "I have performed a medical screening evaluation" and "no emergency medical condition exits"

Clinical Impression

- Diagnosis: Exacerbation of chronic mental illness Medical screening exam.

Disposition

- Disposition Type: MSO (medical screening only)

- Condition: Stable

- Followup with: Southern NV Adult (mental health facility) in 1 day

The Suicide Risk Screening form dated 1/4/2010 indicated:

- The checklist stated "Patient has suicidal ideations? (was slashed through) but then indicated If yes: "no plan" was checked off

- In a subquestion to 2. the question stated "If the patient is expressing passive thoughts of suicide with no plan consider the following with subquestions a-g, the following was indicated for the patient:

"d. Currently has one or more of the following psychiatric illnesses: Major Depression and Borderline Personality Disorder"

"f. Patient has a recent or impending major loss: Homeless"

The subsequent instructions on the form indicated :

"If patient answers "yes" to question one indicating only passive ideation but any of "a-g" are present, further psychiatric evaluation may be necessary and the treating physician should be contacted as soon as possible and patient should be kept in safe setting." The box for "No evaluation ordered" with the "reason" was not documented and the box for Psychiatric Evaluation ordered" was not checked. The psychiatric screening form was incomplete. Also the form indicated LPN (licensed practical nurse) completion and co-signed electronically by an RN at the bottom of the page. There was no documentation acknowledging a physician review of the form.

The Emergency Department Visit Record stated at 1800 (6pm): "Patient here stating that he has been off his medications for four days, Patient was seen here last week and sent to (mental health facility), did not follow their instructions and did not return to outpatient for medications. Patient is homeless at this time. Seen by PA (physician's assistant) and discharged home. Patient refused to sign discharge paper. No suicidal ideations."

The documentation in the record lacked a complete evaluation to ensure the patient had no suicidal ideation and plan, which subsequently failed to demonstrate safe discharge of a patient with a psychiatric history who was known to be noncompliant with his medications and instructions in the past, was to comply with current instructions which he refused to sign, and who reportedly just became homeless.

Interview

On 3/9/10 at approximately 4:30pm, the PA indicated the patient was upset due to a situational thing at the group home. The PA revealed she asked the patient, "If you leave here are you going to harm yourself?" and the patient responded he would not. The PA added the patient said he had not intended to commit suicide before being discharged, but he was upset because he was kicked out of the group home. When asked where in the patient's records did the PA document the interaction, the PA responded she was not aware of a place to record those comments. The PA referred to the Suicide Risk Screening form and its documentation canceled out that the patient was a risk to self. The PA added she now realized a place existed to put her notes and that she would do so from now on.