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Based on observation, interview and document review, the facility failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) rights information in locations likely to be noticed by all individuals, including the entrance, admitting area, waiting room and treatment areas.

Findings:

Observations made during the Initial Tour of the Emergency Department (ED) on 9/13/11 at 11:52 a.m. and a follow-up tour starting on 9/13/11 at 1:14 p.m. revealed one sign containing the four required EMTALA posting statements. A 9 ?" wide by 11" long sign, placed 55" from the floor to the right of ED Registration window 1, displayed public information related to emergency medical screening exams, stabilizing treatment, appropriate transfers when necessary and acceptance of MediCal (state) health insurance.

No similar signage was observed near ED Registration window 2, in the designated ED waiting area, in the triage room, in one randomly-chosen ED examination room or outside the ambulance bay.

In a 1:16 p.m., 9/13/11 interview, ED Registration Representative 1 stated ED patient registration was done at one of two ED lobby windows or at the ED patient bedside. She stated walk-in patients who need to be immediately assessed were registered at the bedside.

In a 1:19 p.m., 9/13/11 interview, ED Registration Representative 2 stated written information provided to patients prior to a medical screening examination included the "Conditions of Registration, revised 2/08" and a "Notice of Privacy Practices", effective date 4/14/03.

Review of these documents revealed no EMTALA rights information. Thus, in absence of prominent signage, patients in the waiting area, ED Registration window 2 or the treatment area had no access to EMTALA rights information.

Review of the facility policy, effective 10/10, indicated, "All Dedicated Emergency Departments ...will post appropriate signage notifying individuals of their right to a Medical Screening Examination and Stabilizing treatment as required by EMTALA ....Each Dedicated Emergency Department ...will post signage in places likely to be noticed by all individuals entering the Dedicated Emergency Department, including the entrance, admitting area, waiting room and treatment area ....The signage must be visible from anywhere in the area or a distance of twenty feet, whichever is less ....The Hospital will ensure that the signage is ...conspicuously posted in accordance with EMTALA and this 'Posting of Signs' policy."

Based on interview and record review, the facility failed to maintain records related to patients who were transferred from the hospital for a period of five years from the date of the transfer for seven of 19 sampled psychiatric patients (1, 2, 4, 5, 7, 17, 20).

Findings:

On 9/14/11 at 11:10 a.m., an interview was held with a Tuolumne County Behavioral Health Crisis Clinician (TBH CC) who stated she performed approximately 45 psychiatric evaluations in the facility ED each month. The TBH CC stated she completed a 51-50 72 hour Involuntary Hold if the patient was a danger to themselves or others. In addition, the TBH CC completed a two page form titled Triage-Client Contact and a Client Diagnostic Review for ED staff to review. If the patient was admitted to the ED on a 51-50 hold, the TBH CC stated she would complete an Advisement Form to support the 51-50 in place by law enforcement.
In review of the records of 19 patients who were transferred to an acute care psychiatric facility, the following was noted:
a. Patient 1, admitted on 6/30/11, had no evidence of the Triage-Client Contact or the Diagnostic review, which were to be completed by the TBH CC, present in the medical record.
b. Patient 2, admitted 5/5/11, had no evidence of the Advisement Form, Triage-Client Contact, or Diagnostic Review, which were to be completed by the TBH CC, present in the medical record.
c. Patient 4, admitted 6/12/11, had no evidence of the Triage-Client Contact, which was to be completed by the TBH CC, present in the medical record.
d. Patient 5, admitted 7/6/11, had no evidence of the Triage-Client Contact or the Diagnostic Review, which were to be completed by the TBH CC, present in the medical record.
e. Patient 7, admitted 7/28/11, had no evidence of a 51-50 present in the record. In addition, there was no evidence of the Triage-Client Contact or the Diagnostic Review, which were to be completed by the TBH CC.
f. Patient 17, admitted 1/31/11, had a 51-50 hold by law enforcement with no Advisement Form completed by the TBH CC. There was no evidence of the Triage-Client Contact, which was to be completed by the TBH CC, present in the medical record.
g. Patient 20, admitted 3/20/11, had no evidence of the Triage-Client Contact, which was to be completed by the TBH CC, present in the medical record.
In an interview with the Vice President of Patient Services (VPPS) and the Director of Quality Risk Management (DQRM) on 9/15/11, they acknowledged they did not consistently find the behavioral health records which were to be completed by the TBH CC in the facility medical record. They acknowledged there was no reliable system to track these documents. In addition, they acknowledged there was no consistent and standard practice for documenting what forms had been sent to the receiving facility.

Based on observation, interview and record review, the facility failed to ensure two of 19 sampled patients (1, 17), who presented to the Emergency Department (ED) between 1/1/11 and 6/30/11 with psychiatric diagnoses (including suicidal and homicidal ideations or an altered level of consciousness) received ongoing assessments and monitoring to ensure stabilization of an emergent condition.

These failures resulted in the potential for the undetected deterioration of an emergency medical condition which would place patients at risk for harm, including elopement.

Of the 19 sampled patients with a psychiatric emergency, there were two actual elopements (Patients 1, 17) from the facility during their stay in the ED. Findings:
1. Patient 1, a 64 year old with prior psychiatric illness, presented to the ED on 6/30/11 at 6:03 p.m. with a diagnosis of an altered mental state. Patient 1 was accompanied by a family member who stated Patient 1 had been "acting out" by throwing things and was having religious delusions. In a form titled ED Physician Notes, (identified by the facility as the Medical Screening Exam), dictated 6/30/11 at 7 p.m., the physician stated the family member was concerned that Patient 1 "may be dangerous to herself or others" as she had stopped taking her Klonopin (a medication to control seizures and panic disorder) a month ago and "symptoms have developed" over the last few days. The ED physician described Patient 1 as cooperative, but hostile and somewhat distant. The ED Physician diagnosed Patient 1 as "gravely disabled, depression, psychotic disorder" and stated Patient 1 was medically stable for transfer to a psychiatric facility. The ED Physician ordered a psychiatric evaluation by the county prior to transfer. The psychiatric evaluation was done by the Tuolumne County Behavioral Health Crisis Clinician (TBH CC) at 8:19 p.m. and Patient 1 was placed on a 51-50 72 hour Involuntary Hold.

In an interview with the ED Nursing Manager (EDM) on 8/24/11 at 2:30 p.m., he stated Patient 1 was in a hallway bed across from the nursing station as it was an "extremely" busy night and multiple patients were being held for admission. The EDM stated all the ED beds, including the bed (Room 6) designated for psychiatric patients, were full. He stated staff reported Patient 1 was cooperative so there were no attempts to restrain her. The EDM stated the facility does not use "sitters" for patients on a 51-50 (a 72 hour Involuntary Hold) although they are "having conversations about this". The EDM stated Patient 1's family member, who had been with Patient 1 throughout the stay, had left the facility at approximately 11 p.m. The EDM stated staff saw the patient exit through the door to the ED lobby at 1:47 a.m. The EDM further revealed an ED technician followed the patient approximately two blocks away but Patient 1 refused to return to the facility. The EDM stated law enforcement was notified, however Patient 1's family member was not notified due to "HIPAA" (regulations which define rules for the privacy and confidentiality of health information). Patient 1 was found dead in a field within a mile from the facility on 8/9/11.In a concurrent review of Patient 1's medical record with the EDM, the following was noted:
a. 6/30/11 6:17 p.m. Initial Triage and Assessment, including vital signsb. 7/1/11 1:47 a.m. Patient eloped out the triage door.b. 7/1/11 3:02 a.m. Patient Eloped and Officers aware. (actual elopement time 1:47 a.m.) c. 7/1/11 3:01 a.m. Police called search off. TBH notified.
There was no evidence of any observations, assessments or ongoing monitoring, including a psychiatric or behavioral assessment. There were no vital signs taken after Patient 1's admission. Patient 1 did not receive any medications while in the ED.
The EDM acknowledged there was no evidence of any ongoing monitoring or re-assessment, of Patient 1 throughout the evening and described the documentation as "very poor". The EDM stated there were no unit specific policies directing staff on the performing and timing of assessments of patients in triage, the waiting area or the ED.
The EDM revealed the "county mental health crisis worker" (TBH CC) comes in when called to evaluate a patient and would place the patient on a 51-50 72 hour Involuntary Hold (if not done prior to admission) if he/she was determined to be a danger to themselves and/or others. The EDM revealed the TBH CC was responsible for making arrangements for transfer to a psychiatric facility after the patient was determined to be medically cleared. The EDM stated the "crisis worker" was not required to stay in the facility or assist with the ongoing assessment or monitoring of patients with a psychiatric emergency. The EDM, employed at the facility for five months, stated he was not aware of any education or training provided to the ED nurses on the management of psychiatric patients. The EDM further revealed there were no policies and procedures for the management of psychiatric patients with an emergent condition.On 9/14/11 at 11:10 a.m., an interview was held with the TBH CC who was assigned to evaluate Patient 1 in the facility ED prior to transfer to a psychiatric facility. The TBH CC reviewed Patient 1's medical record with the SA and acknowledged she had completed the 51-50 72 hour Involuntary Hold. The TBH CC acknowledged Patient 1 had "reported despair, hopelessness and SI" (suicidal ideations). The TBH CC stated she placed the 51-50 form on the top of Patient 1's medical record with a two page form titled Triage - Client Contact and a Client Diagnostic Review for ED staff to review and forward to the receiving facility. The TBH CC stated she discussed Patient 1's clinical status with the ED physician and the ED charge nurse (defined by the facility as the clinical lead) and notified staff when she left the facility.On 9/14/11 at 1 p.m., an interview was held with the Registered Nurse (RN1) who triaged Patient 1 on 6/30/11 at 6:03 p.m. RN1 stated the frequency of re-assessments of patients with a psychiatric emergency "depends on their condition" and "if the patient is sleeping we may not do them". RN1 was not aware of a policy for re-assessments but stated "we have been told as a general rule to assess psychiatric patients every hour". RN1 stated there may not be documentation to reflect "ongoing dialogue" with the patient to evaluate the potential for elopement. On 9/14/11 at 7:40 a.m., an interview was held with the Registered Nurse (RN2) who was assigned to Patient 1 at the time of her elopement. RN2 stated she was the Clinical Lead that evening, however it was "typical" for the Clinical Lead to take a patient assignment. RN2 stated it was extremely busy that night ("we were slammed") with "several psych" patients in the ED. RN2 stated there were "very limited" communications between the TBH CC and staff. RN2 stated she was not aware Patient 1 was on a 51-50 hold and she "thought they [TBH CC] were still here" and "I thought she [Patient 1] was voluntary" at the time of the elopement. RN2 further stated "this patient may have voiced SI [suicidal ideations] to Behavioral Health but did not voice it to hospital staff or MD". RN2 did not recall reviewing any assessment forms placed in the medical record by the TBH CC. RN2 further revealed "ideally behavioral health talks to us and tells us their plan" and "some communicate better than others". RN2 did not recall Patient 1 expressing any suicidal ideations or plans to elope. RN2 stated re-assessments are "typically" done every hour "depending what is going on" and every two hours "if behavioral health was there intervening". She did not recall any facility policies regarding re-assessments of patients in the ED. RN2 described a "hot shot", comprised of three medications (Haldol, an anti-psychotic medication, Ativan,an anti-anxiety medication and Benadryl, an anti-histamine that causes mild sedation) given to patients who required sedation, but stated Patient 1 was cooperative and did not require physical or chemical restraint. RN2 further stated patients were assessed one hour after receiving any sedation. RN2 stated another nurse reported that Patient 1 had eloped through the internal door to the triage room. RN2 stated the police had been called and conducted a search but there were no attempts to contact Patient 1's family. RN2 acknowledged there was no documentation of relevant information regarding Patient 1's condition and the circumstances pertaining to her departure in the medical record.
In an interview on 9/14/11 at 8:35 a.m., with the Emergency Department Technician (EDT) who followed Patient 1 out of the facility, he stated Patient 1 was dressed in street clothes and crossed the street. For 15-20 minutes, the EDT stated he attempted to get Patient 1 to return to the facility however she refused. When he told Patient 1 the police would be called, the EDT stated Patient 1 responded "they will never find me". When asked if he had documented the elopement and his encounter with Patient 1, he replied "no" and stated that would be the responsibility of the charge nurse.
In review of a facility policy titled Medical Screening Examination and Stabilization, approved 10/5/10, there was stipulation: "The treatment area nurse, in addition to following department policies and procedures, will record the following information in the patient chart: a) Continued patient assessment process: narrative documentation reflecting the patient care, nursing interventions, education, response to treatment and medication" and "Vital signs every two hours or more frequently as condition mandates and on discharge or Transfer".
In a facility policy titled Intellicare Patient Physical Assessment/Reassessment Guidelines (identified by the facility as a nursing department policy which included the ED), dated 4/09, there was stipulation the nurse would determine how often to reassess a "patient complaint" and the nurse must make a clinical judgment on what was to be observed and how often. The policy defined parameters to be used in an adult assessment which did not include a psychological or psychiatric assessment. The policy further stipulated that "patient reassessment is completed according to unit specific policies, protocols and/or standards ...which describe minimum reassessment intervals." On Page 5 of the policy, the ED standard was defined as "patient status 1-2 hrs or more as condition warrants" and "ongoing assessment documented".
A corporate policy titled Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA), dated 10/2010, pages 12-13, revealed: "When it is determined the individual has an Emergency Medical Condition the Hospital will...provide... Stabilizing treatment for the individual" and "The Hospital will continue to monitor and record the individual's condition throughout his/her stay in the Dedicated Emergency Department".
In review of a policy titled Pain Management - Assessment Reassessment, reviewed 3/08, there was stipulation on page 1: "Reassessment of pain is within one hour of interventions performed".In review of Patient 1's facesheet, the family member who brought Patient 1 to the ED and stayed with her until 11 p.m. was noted as Patient 1's contact person.
In review of a facility policy titled Leaving Against Medical Advice and Elopement, dated 11/23/10, page 2, there was stipulation: "When a nurse suspects that a patient has left the hospital grounds without a discharge order: c. The patient's emergency contact person is notified by either the physician or by hospital staff" and "when available, security personnel are contacted to help locate the patient".
In an interview with the Director of Quality/Risk Management (DQRM) on 9/14/11 at 3 p.m., she acknowledged security had not been informed of Patient 1's elopement. Security documents for 6/30/11 and 7/1/11 were reviewed and there was no reference to Patient 1's elopement.
In review of a corporate policy titled Patient Elopement; Dedicated Emergency Department (DED), dated 10/2010, page 2, there was stipulation: "The patient chart will reflect the time the patient left the department and any other relevant information regarding the patient's condition or the circumstances pertaining to his/her departure" and "the emergency physician will be notified to determine if immediate action is needed (such as contacting security or the patient's family).
In an interview on 8/25/11 at 10:30 a.m., the deputy coroner assigned to conduct Patient 1's autopsy stated there was no way to determine the cause of death due to the decomposition and mummification of Patient 1's body. The deputy coroner stated it "looked like" Patient 1 had "wandered to that spot" within a mile of the facility and possibly expired from dehydration.
2. Patient 17, a 40 year old, presented to the ED on 1/31/11 at 5:16 p.m. following statements he had a gun and was going to kill himself. Patient 17, on a 51-50 as a danger to himself, was accompanied by law enforcement. In review of a form titled ED Triage and Initial Assessment, the nurse assigned Patient 17 a triage level of 3, urgent. The Triage Nurse documented Patient 17 had responded "yes" when asked if he was thinking of killing or harming himself. There was no evidence of any further assessment or re-assessment, including psychiatric or neurological parameters. Patient 17 eloped from the ED at 7:11 p.m.Patient 17 presented again to the ED on 2/1/11 at 9:02 a.m. and was assigned a triage level 2, very urgent. Patient 17 was triaged at 9:15 a.m., received an initial assessment at 9:18 a.m. and a psychiatric nursing assessment at 10 a.m. There was no evidence of any further re-assessments or monitoring prior to an appropriate transfer by cage car to an in-patient psychiatric facility at 4 p.m. There was no evidence of any psychiatric evaluation by the TBH CC, although there was reference to a visit in the ED Physician Progress Notes. None of the patients reviewed had vital signs, which include an assessment of pain, routinely done every 2 hours and/or on transfer to the psychiatric facility as stated in the facility policy titled Medical Screening Examination and Stabilization, approved 10/5/10 (see above item 1).

Based on staff interview and record review, the hospital failed to ensure safe interfacility transfer for four of 19 patients (2, 4, 18, 24) when there was no documentation that necessary Emergency Department medical information had been sent to the receiving hospitals at the time of or following the transfers.

Findings:

1. In review of a facility form titled Interfacility Transfer, there was a "Documentation of Information Sent" section which listed the transferring patient's documents/records which were sent to the receiving facility.

a. Patient 2's Interfacility Transfer document dated 5/6/11 did not indicate the ED record and Nursing Notes were sent to Patient 2's receiving facility. This would have included nursing assessments and care provided. There was no evidence in the clinical record that indicated these records were sent at a later time.

b. Patient 4's Interfacility Transfer document dated 6/13/11 did not indicate that ANY records were sent to Patient 4's receiving facility (this section of the form was completely blank). This would have included all relevant information regarding Patient 4's emergent condition including patient history and medical screening examination, nursing assessment and care, all diagnostic studies and treatment provided as well as the patient request for transfer. There was no evidence in the clinical record that indicated these records were sent at a later time.

c. Patient 18's Interfacility Transfer document dated 2/13/10 indicated the ED record was "Not Applicable" (N/A) to be sent to Patient 18's receiving facility. Therefore there was no evidence that all all relevant information regarding Patient 7's emergent condition including patient history and medical screening examination, nursing assessment and care, all diagnostic studies and treatment provided as well as the patient request for transfer were received by the accepting facility. There was no evidence in the clinical record that indicated these records were sent at a later time.

d. Patient 24's Interfacility Transfer document dated 9/13/11 did not indicate that ANY records were sent to Patient 24's receiving facility (this section of the form was completely blank). Therefore there was no evidence that all all relevant information regarding Patient 7's emergent condition including patient history and medical screening examination, nursing assessment and care, all diagnostic studies and treatment provided as well as the patient request for transfer were received by the accepting facility. There was no evidence in the clinical record that indicated these records were sent at a later time.

In review of a corporate policy titled Patient Transfer, dated 10/2010, page 4, Medical Records, there was stipulation: "The Hospital will send copies to the receiving facility of all medical records pertaining to the individual's Emergency Medical Condition that are available at the time of transfer. These records will include copies of the available history, records related to the Emergency Medical Condition, observation of signs or symptoms, preliminary diagnosis, results of diagnostic studies..., treatment provided, results of any tests, and the informed written consent or Physician Certification." The policy further directed: "The copies of other records...not available at the time of Transfer will be sent as soon as possible after the Transfer".

On 9/14/11 at 11:10 a.m., an interview was held with a Tuolumne County Behavioral Health Crisis Clinician (TBH CC) who stated she performed approximately 45 psychiatric evaluations in the facility ED each month. The TBH CC stated she completed a 51-50 72 hour Involuntary Hold if the patient was a danger to themselves or others. In addition, the TBH CC completed a two page form titled Triage-Client Contact and a Client Diagnostic Review for ED staff to review. If the patient was admitted to the ED on a 51-50 hold, the TBH CC stated she would complete an Advisement Form to support the 51-50 in place by law enforcement.
Further review of the medical records showed missing behavioral health assessments for patients 2 and 4.
a. Patient 2, admitted 5/5/11, had no evidence of the Advisement Form, Triage-Client Contact, or Diagnostic Review, which were to be completed by the TBH CC, present in the medical record.
b. Patient 4, admitted 6/12/11, had no evidence of the Triage-Client Contact, which was to be completed by the TBH CC, present in the medical record.
In an interview with the Vice President of Patient Services (VPPS) and the Director of Quality Risk Management (DQRM) on 9/15/11, they acknowledged they did not consistently find the behavioral health records which were to be completed by the TBH CC in the facility medical record. They acknowledged there was no reliable system to track these documents. In addition, they acknowledged there was no consistent and standard practice for documenting what forms had been sent to the receiving facility.