HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to ensure the facility's emergency department had policies and procedures, as part of the EMTALA obligation, to address the use of safety contracts for two (2) of twenty-two (22) sampled patients presenting to the facility seeking emergency care (Patient #13 and Patient #21).

The findings include:

Patient #13 and Patient #21 presented to the facility's emergency department with complaints which included but were not limited to suicidal ideations. Patient #13 presented to the facility's ED (emergency department) on 5/20/17. Patient #21 presented to the facility's ED on 8/5/17 and 8/6/17. Both patients were discharged after signing safety contracts

Patient #13 presented to the facility's ED (emergency department) on 5/20/17 voluntarily requesting inpatient treatment due to being off medication, 'wanting to harm (himself/herself),' and possible hallucinations".

On 5/21/17 at 7:57AM, the following information was documented by SM #17 (a resource clinician/hospital employee): "Met with patient, (name omitted), in the ED at 0715 this a.m. (Patient) was pleasant, friendly, denied current thoughts or plan of (suicidal ideation/homicidal ideation), ...wishes to leave the hospital and go to (local mission name omitted). (Patient) denies (substance abuse), appears to relatively [sic] healthy, no pressured speech noted, is clear and oriented to time, place, name, and reason for being in the (hospital). ... (Patient) agrees to help create a safety plan, is aware of (local mission name omitted), and expresses desire to go to the facility for a place to stay, and to connect with (local community service board) for services. ...(Patient) signs safety plan and receives copy. (ED physician name) is attending physician in the ER (emergency room), and agrees with this plan for (discharge) from the ER."

Patient #13 signed his/her 'Community Safety Plan' on 5/21/17 at 7:30AM. This plan included emergency contact numbers (including 911) and a contact number for a follow-up with the local community service board. The form indicated the patient "denies thoughts of self-harm".

Patient #21 was seen at the facility's ED on 08/05/17, 08/06/17 and 08/07/17. The patient verbalized suicidal ideations on each visit, and on the third visit, stated he/she had taken an overdose of medication. On both the 8/5/17 and 8/6/17 visits, the patient signed a safety contract.

On 08/06/17 at 12:25 PM, SM #12 documented, "Representative from the (crisis program) and our resource clinician re-evaluated the patient. Patient has contracted for safety and agreed to be discharged. (He/she) will follow-up with (Community Services Board (CBS)). I also had our social worker, (name omitted) speak with the patient regarding (his/her) living situation and if there is anything that can be done to help make follow-up easier for (him/her)."

On 08/06/17 at 4:57 PM, Patient #21 again presented to the facility's ED, with the police, for the complaint of, "Patient called 911 stating out of medication and having SI [Suicidal Ideation], also hearing voices telling me to jump into traffic."

On 8/7/17 at 12:19 PM, the ED physician SM #13 documented the following: "I have personally interviewed and examined this patient. On my history, the patient complains of feeling intermittently suicidal. He/she did state that he/she had a plan to jump into traffic per the prior notes. I examined him/her with the resource clinician and patient is willing to sign a safety plan. The (crisis program) staff has contacted (his/her) family. Everyone on board with the plan.

On 08/7/17 at 12:30 PM, Patient #21 signed a Community Safety Plan.

A review of the facility's EMTALA policy and procedure, with a most recent review date of "12/09", failed to reveal policies regarding the use of safety contracts (community safety plans) with patients presenting to the emergency department.

On 8/9/17 at 9:04Am, SM #18 (Director of Outpatient Behavioral Health) was interviewed. SM #18 reported there were no policies and procedures to guide the use of the "community safety plan"; SM #18 reported it was part of the clinical practice.

Based on interviews and document review, it was determined the facility staff failed to have evidence of stabilizing treatment for two (2) of twenty-two (22) sampled emergency patients (Patient #13 and Patient #21). Both patients were discharged after signing safety contracts and subsequently returned the following day with a complaint of wanting to harm themselves. Patient #21 returned for a third day in a row, stating an overdose of medication.

The findings include:

1. Review of Patient #13's medical record revealed that the patient arrived to the Emergency Department, voluntarily via police, on May 20, 2017, at 11:56 AM, with a chief medical complaint of wanting to harm self. Patient was also documented as "muttering ... & rocking back & forth in chair when not speaking to staff." Further review of the patient's medical record revealed that the patient expressed "active suicidal thoughts of killing oneself and patient reports having 'some intent to act on such thoughts' ..."

In a clinician note dated May 20, 3017, timed at 2:32 PM, documentation included that Patient #13 was not taking medications and "seems to be decompensating, so IP (inpatient) Tx (treatment) is warranted."

Review of a Behavioral Health note, dated May 21, 2017, and timed at 5:20 AM, revealed that the clinician spoke with the patient to ask the patient if they knew why they were there. The patient responded that they were in the hospital to get treatment for their "mental condition." Further review of documentation revealed "[patient] is aware that [name of a treatment facility] does not have a bed; therefore, [patient] will need to go to another hospital. [Patient] is accepting of treatment. ... Clinician will continue to locate an inpatient facility for stabilization and medication management.

Review of documentation dated May 21, 2017 and timed at 6:55 AM, revealed "patient is pacing ... line of sight, room secure."
Documentation review dated May 21, 2017, and timed at 6:56AM, noted Staff Member #13 (an ED physician) ordered Ativan 1mg to be administered by mouth as a one-time dose to be scheduled for 'now'. Documentation indicated the patient was administered the medication on 5/21/17 at 7:04AM; no documentation was found to indicate the patient was reassessed to determine the effectiveness of this medication.

Review of documentation, timed at 7:04 AM, revealed "patient requested a cab to [name of a homeless shelter]. Pt. is singing." At 7:13 AM, the patient was documented as "pacing and laughing loudly." The 'line of sight' documentation began to reflect different behaviors than in previous documentation.

Review of medical documentation, dated May 21, 2017, and timed at 7:57 AM, revealed that a social worker assessed the patient at 7:15 AM and documented the following " ... denied current thoughts or plan of suicidal ideation ... wishes to leave the hospital and go to [name of local mission- homeless shelter] ... appears relatively healthy ... is clear and oriented to time, place, name, and reason for being in the [hospital] ... agrees to help create a safety plan ... patient signs safety plan with phone numbers and [name of local community service board], is provided times of walk-in intakes for individuals ... [Name of ED physician] is attending physician in the ER, and agrees with this plan for discharge from the ER. ..."

Review of documentation, timed at 7:18 AM revealed that the emergency department physician was in the room talking with the patient and the patient expressed a desire to leave the facility.
At 7:26 AM, the patient was documented as talking to self and stating "you can't have sex, it's what made you sick."

On May 21, 2017, at 7:30 AM, it was documented Patient #13 signed a 'Community Safety Plan'. The safety plan included emergency contact number (911) and a contact number for follow up with the local community service board. The form included documentation the patient "denies thoughts of self-harm".

On May 21, 2017, at 7:32 AM, the 'line of sight' documentation noted Patient #13 starting to talk to self when the clinician left the patient's room. At 7:39 AM, the patient was documented as being anxious, hallucinating, pacing, laughing and talking to self. The patient was also noted to have "removed second gown, turned into the corner, and opened [patient] gown." At 7:41 AM, a clinician informed the patient that [local mission] has beds and the clinician will work on getting [patient] a cab to the mission. [Patient] "laughing loudly".

A physician documented on May 21, 2017, timed at 7:43 AM, that the patient was seen by this physician while working on a prior shift. The physician noted reevaluating the patient the morning of May 21, 2017 and the patient would like to go back to the mission. "[Patient] was reevaluated by resource clinician, [patient] signed a safety plan, [patient] does not feel like [patient] is going to hurt [patient] and knows to come back if [patient] feels that [patient] wanted to hurt [patient]. I think at this time [patient] is safe to be discharged."

On May 21, 2017, timed at 7:47 AM, 'line of sight' documentation included, "[Patient] asking "If a black person was a white person and a white person was a black person in a former life, then everyone was white at some point. I wonder then God did you set it up that way"? [sic] [patient] continues to laugh." At 7:55AM - "[patient] laughing and pointing towards the wall and states "God, you are funny for doing that".

On May 21, 2017 at 7:59 AM, a nurse documented that Patient #13 was insistent on leaving, spoke with resource clinician and contracted for safety. Follow up care and when to return discussed with patient. Patient #13 signed discharge paperwork on 5/21/17 at 7:59AM.

A review of the medical record failed to find documented evidence that Patient #13 was informed of the risks of leaving prior to receiving treatment or the benefits of staying.

Patient #13 returned to the facility the following day, on May 22, 2017 at 11:52PM, with a chief complaint of "hearing voices" and "suicidal". The patient was subsequently admitted to the facility's behavioral health unit.

On August 9, 2017 at 11:25AM, SM #4 (the Quality Coordinator) reported no documentation was found in Patient #13's 5/20/17 - May 21, 2017 emergency department (ED) clinical documentation to indicate the ED physician contacted the on-call physician for Psychiatry.

The patient's medical record lacked evidence/documentation of searches for an inpatient psychiatric bed for Patient #13.

On August 8, 2017 at 3:42PM, SM #17 was interviewed about his/her interaction with the Patient #13. Initially SM #17 could not remember the patient. SM #17 was provided the patient's clinical documentation to review. SM #17 reported he/she did not contact facilities seeking an inpatient bed for Patient #13. SM #17 reported he/she was not provided a verbal report by the resource clinician who interacted with the patient prior to SM #17 assuming the patient's care.

The surveyor was informed that communication between resource clinicians during the transfer of care is not always verbal, communication often occurs by using an electronic log. The surveyor was shown this electronic log (and provided a copy) of what related to Patient #13. This log did not include documentation of which in-patient facilities were contacted and when the facilities were contacted; this electronic log did not document the response of in-patient facilities to the request for a bed for Patient #13. The facility staff were unable to provide the survey team with documentation of which facilities were contacted seeking a bed for Patient #13, when these facilities were contacted, and when/if the contacted facilities responded. When asked about Patient #13's documented behavior in the hour prior to discharge, SM #17 reported he/she "was not aware of (the) behavior".

On the afternoon of August 8, 2017 SM #13 (the ED physician who discharged Patient #13) was interviewed. SM #13 was asked about his/her decision to discharge Patient #13. SM #13 reported the patient was voluntary and stated if the patient was not a threat to self or others then he/she was not able to hold the patient against his/her will. SM #13 reported that Patient #13 had been seen by the 'resource' staff and had contracted for safety. When asked if he/she had been aware of the behaviors documented by the staff providing 'line-of-sight' observation, SM #13 reported he/she was unsure if he/she had been aware of the aforementioned observations/behaviors. SM #13 reported that hallucinations would not have necessarily prevented the patient from being discharged. SM #13 reported if the patient had capacity to be discharged with a safety contract then the patient was okay to be discharged.

SM #13 was asked about the Ativan that he/she had ordered for Patient #13 on May 21, 2017 at 6:56AM; SM #13, after reviewing sections of the chart, stated it was ordered "probably for agitation ... is my guess." SM #13 was asked about documenting a reason for the Ativan order; SM #13 reported it would not be necessary to document a separate note.

SM #13 was also asked about providing Patient #13 with the medications or a prescription for the medications the patient had stopped taking; SM #13 stated he/she would not order some types of medication, the patient would need to see a physician and that the 'resource' staff had provided the patient with that information.

On August 9, 2017 at 10:20AM, SM #18 (Director of Outpatient Behavioral Health) provided the survey team with information, from a reference book entitled The "Psychiatric Emergencies: How to Accurately Assess and Manage the Patient in Crisis" (second edition). This reference book included a section on suicidal behaviors. The following information related to suicidal behaviors was found under the heading of "Treatment and Disposition": "1. The disposition is contingent upon the imminence of acting on suicidal ideations or plan, current risk factors, available protective factors, symptom management and ability to control suicidal impulses. The client presenting in an acute psychotic or intoxicated state will have difficulty controlling his or her impulses and poses higher suicide risk because of the disinhibiting properties of these conditions. 2. The nature of external controls and available support systems accessible to the client. For instance, the older client who lives alone, if family members are willing to stay with him and administer medications, is more likely to have strong external controls. In contrast, a homeless client who has stopped taking medications and threatening to kill himself has poor external controls, poor support systems and few protective resources requires inpatient hospitalization that affords external control against suicidal impulses and medication stabilization ..."

On August 9, 2017 at 1:15PM, SM #10 (a nursing quality staff member) reported he/she was unable to find: (a) a facility policy and procedure for safety contract/community safety plan and (b) a facility policy and procedure for completing a bed search for behavioral health patients.

The following information was found in a facility policy for the facility's behavioral health department, entitled 'Suicide Assessment And [sic] Prevention" (the most recent revised date was 7/15): Discharge Planning; 1. A well developed discharge plan is an important element in the safe management of the suicidal patient and sets the stage for a successful recovery. 2. Pre Discharge [sic] Suicide Assessment: a. Prior to discharge, an RN or licensed therapist shall assess current level of suicide risk, presence or absence of plan (including lethality if present), documentation of patient and family, as appropriate, education regarding the patient's suicide prevention/safety plan, and documentation of immediate communication with the patient's physician for any positive findings. This assessment is to be documented in the progress notes. b. Prior to discharge the physician is to perform a comprehensive assessment of the patient's suicide risk. This assessment should include: current level of suicide risk, presence or absence of a plan (including lethality if present), review of any significant self injurious [sic] or suicidal activity while hospitalized, presence of physician reviewed and approved suicide prevention/safety plan, justification for discontinuation of any current heightened levels of observation or suicide precautions, and clinical justification for discharge or transfer to a lower level of care. This assessment is to be documented in the MD Progress Notes or in the Discharge Summary."

On August 9, 2017 at 9:04Am, SM #18 (Director of Outpatient Behavioral Health) was interviewed about the care provided to Patient #13 by the facility's resource clinicians. SM #18 reported there were no policies and procedures to guide the use of the "community safety plan"; SM #18 reported it was part of the clinical practice. SM #18 was asked about the expectation for how long a resource clinician should wait before following-up after the initially contacting a facility for an inpatient bed; SM #18 was unable to give a specific time frame for when to follow-up; SM #18 stated it would depend on what else was going on during the same time period.

On August 9, 2017 at 1:30PM, SM #2 (Director of Risk Management) provided a blank copy of the "Community Safety Plan"; SM #2 confirmed no facility policy and procedure was found related to the "Community Safety Plan".


2. Patient #21 was seen in the emergency department on both August 5, 2017 and August 6, 2017 for suicidal ideations. The patient was discharged when an inpatient psychiatric bed was not found and after the patient signed a safety contract. The patient went to the emergency department for the third time, on August 7, 2017, stating he/she had overdosed on medication and was subsequently admitted to an inpatient psychiatric bed.

The following information was noted during the medical record review for the ED admission beginning on August 5, 2017. Patient #21 arrived in the ED on August 5, 2017 at 6:29 PM. At 6:31 PM, the patient reported plans to overdose ...has been off medication for at least a week ...does not have local prescriber ...multiple hospitalizations for either an actual overdose or plans to overdose.

A physician note dated August 5, 2017 at 6:42 PM, documented discussing the patient with a behavioral health clinician who recommended "inpatient psychiatric hospitalization. Bed search is ongoing at this time." No documentation was found in the medical record regarding which psychiatric facilities were contacted during the bed search, nor the response of such facilities.

On August 5, 2017 at 7:37 PM, a behavioral health clinician documented, "Pt (patient) stated that if [patient] returned to [local shelter], [patient] would overdose on [patient] medication." ...A month ago [patient] overdosed on Depakote ...reported hearing voices telling [patient] to take pills .... [Patient] is voluntary for inpatient psychiatric admission. "Patient requires long term follow up after hospitalization ..."

On August 6, 2017, timed at 11:45 AM, 'line of sight' documentation included, "anxious". At 12:27 PM, "pacing room". At 12:46 PM, "anxious".

On August 6, 2017 at 12:25 PM, an ED physician documented Patient #21 was re-evaluated by clinicians, contracted for safety and agreed to be discharged. A social worked also met with the patient to discuss the living situation and what could be done to make follow-up easier for the patient.

Patient #21 signed the discharge form on August 6,2017 at 1:10 PM.

A behavioral health clinician's follow-up note on August 6, 2107 at 1:34 PM included, patient stated no longer experiencing auditory hallucinations and felt safe to discharge. Patient, [crisis clinician] and the note writer developed a community safety plan. Patient agreed to return to the ED if felt unsafe again and agreed to follow up with outpatient providers.

No documentation was found in the patient's medical record to indicate why there was a change in the plan for inpatient admission. Also, no evidence was found that the risks of leaving prior to treatment or the benefits of staying were discussed with Patient #21 prior to discharge.

The same day of discharge, August 6, 2017, Patient #21 presented to the hospital ED again at 4:57 PM with a chief complaint of being out of medications, having suicidal ideations, and hearing voices telling [patient] to jump into traffic.

On August 6, 2017 at 5:49 PM, a behavioral health clinician documented contacting a local psychiatric clinician to report Patient #21 had returned to the ED for suicidal ideations, the ED physician was notified of the contact with the local resource person. Patient #21 reported hearing voices again ...telling [patient] to jump in front of traffic ...patient to ED because feels unable to maintain commitment to safety .... patient stated continued to hear voices while in the ED. "Pt indicated that if d/c (discharged) from ED, [patient] fears [patient] will follow the command.". Patient noted command AH (auditory hallucinations) is worsening in intensity." Recommend impatient psychiatric hospitalization for safety and stabilization. Patient is voluntary. ED physician is in agreement. The facility's inpatient psychiatric unit at capacity, "so bed search will be initiated."

A follow-up clinician note dated August 6, 2017 at 9:00 PM, listed the psychiatric facilities which were included in the bed search with no acceptance at that time. Another note documented on August 7,2017 at 3:19 AM, discussed situation with patient, still voluntary, all hospitals refused acuity or capacity, restart bed search in AM.
On August 7, 2017 at 11:48 AM, an ED physician documented interviewing the patient ...complains of feeling intermittently suicidal ...stated [patient] had a plan to jump into traffic per prior notes ...examined patient with behavioral health clinician, patient willing to sign a safety plan ...." Everyone on board with the plan." "[Patient] has been here for over 20 hours. [Patient] is now saying that [patient] is willing to sign a safety plan, [patient] does not feel like [patient] will hurt [patient]." ...Complaining of left ear pain ...treated with Cortisporin drops.

On August 7, 2017 at 12:26 a behavioral health clinician documented meeting with the patient earlier in the morning, during which the patient denied hearing voices, denied suicidal ideations. Bed search continued with seven (7) facilities listed with responses of one (1) denial and the others at capacity. Local shelter agreed to allow Patient #21 to return to the shelter, patient 'requested wanting to return" to shelter. Patient signed a safety contract stating patient would call a local resource clinician if began experiencing difficulties. "Attempted to assist [patient] in thinking of plans to remain safe, other than that of returning to the ED."

Patient #21 signed the discharge form on August 7, 2017 at 12:30 PM.

Patient #21 returned to the ED approximately eight (8) hours later, on August 7, 2017 at 8:27 PM, saying "I took a bunch of Metformin." The patient was admitted to the facility's behavioral health unit.

On August 9, 2017 at 9:05 AM an interview was conducted with the Director of Outpatient Behavior Health, SM #18. The director stated the facility does not have written policies and procedures to guide staff on performing a search for an inpatient bed for behavior health patients and/or creating a community safety plan with patients being discharged, after presenting with suicidal ideation.