HospitalInspections.org

Based on interview and policy review, the facility failed to ensure that the medical staff has written policies and procedures for the appraisal of behavioral health emergencies and initial treatment in the main Emergency Department.

Findings include:

Review of PolicyStat ID: 14957369 - Plan for the Provision of Care - Emergency Department (ED)/Free-Standing ED, Last Revised 01/2024 documented 9 behavioral health beds. The 9 beds are no longer utilized for treating behavioral health patients. The beds are currently used as a behavioral health holding area once patients are medically cleared.

Interview conducted with Staff H (ED Director of Nursing) on 05/01/2024 at 11:06 AM. Staff H (ED Director of Nursing) stated the ED staff was educated and informed that the behavioral health patients will no longer go to the ED behavioral health unit until they're medically cleared. Staff H (ED Director of Nursing) stated that behavioral health patients are treated in Zone 23. Once medically cleared, the nurse reviews the physician orders and documentation; all medical treatments are discontinued, and the Intravenous (IV) Heparin Lock is removed. The patient is transported to the Behavioral Health Holding Area. If the patient decompensates, they are transferred back into the main ED.

During an interview conducted on 05/01/2024 at 4:30 PM, the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Quality Director and the Patient Safety Director acknowledged that the facility did not provide an updated documented plan for the provision of care in the Emergency Department for the treatment of behavioral health patients.