HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) within its capabilities and capacity, for one patient (#4) out of 30 Emergency Department (ED) sampled cases from 01/01/22 through 01/31/22 and 10/13/22 through 03/13/23. The hospital's average monthly ED census over the past six months was 3,407 for Christian Hospital ED and 4,067 for the Northwest ED.

Findings included:

Review of the hospital's policy titled, "EMTALA Antidumping Compliance of Emergency Department and Hospital Patient (Individual) Transfers to Another Facility," revised 04/2021, showed the hospital must provide an appropriate MSE beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) by qualified personnel as determined by the Medical Staff office Rules and Regulations when an individual presents to the ED and requests examination or treatment for a medical condition. A MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.

Review of the hospital's policy titled, "Medical Screening Exam (MSE)," revised 04/2022, showed current hospital and ED protocol will be followed for the disposition of psychiatric (relating to mental illness) or substance abuse (misuse of alcohol and/or other drugs) patients. When ancillary services of the hospital are necessary to complete the MSE, the ED physician and ancillary services will coordinate services to assure that an appropriate history and physical examination including testing is obtained and provided for all patients.

Review of the hospital's policy titled, "Admissions to the Emergency Department," revised 03/2019, showed no patient will be discharged from the ED without a thorough MSE by an ED or qualified personnel.

Review of the hospital's policy titled, "Mental Health Assessment," dated 12/2021, showed the ED physician or nurse completes their MSE. If the MSE indicates that a Mental Health or Substance Abuse Assessment is warranted, an order will be placed in the medical record and Behavioral Health Intervention (BHI) services will receive an order. The assessing Registered Nurse (RN) or attending physician must make the determination for psychiatric assessment. A Qualified Mental Health Professional (QHMP) would then assess the patient, discuss with the treating RN and the assigned physician.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 01/2022, showed a MSE will be provided for all patients requesting ED services by a Physician; a Physician Assistant (PA) with a supervision agreement with an ED physician; a nurse practitioner (Advance Practice Nurse) with a collaborative practice agreement with an ED physician; an ED RN certified in advanced cardiac life support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) who has access to an onsite ED physician.

Review of Patient #4's medical record showed the following:
- He was a 33-year-old male who presented to the ED via EMS on 01/05/22 at 6:16 PM with a chief complaint of bizarre behavior and had stopped taking his lithium that day.
- He had a past medical history of schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real) for which he was prescribed lithium.
- He denied having thoughts of self-harm (behavior that is harmful or potentially harmful to oneself), suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death).
- Laboratory tests were ordered, but a lithium level was not ordered and a urine drug screen (UDS) was not collected.
- Patient #4 was discharged at 3:05 AM on 01/06/22.
- There was no mention in his medical record that either a QMHP or a psychiatrist was consulted for Patient #4.

Please see A-2406 for additional information.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) within its capabilities and capacity, for one patient (#4) out of 30 Emergency Department (ED) sampled cases from 01/01/22 through 01/31/22 and 10/13/22 through 03/13/23. The hospital's average monthly ED census over the past six months was 3,407 for Christian Hospital ED and 4,067 for the Northwest ED.

Findings included:

Review of the hospital's policy titled, "EMTALA Antidumping Compliance of Emergency Department and Hospital Patient (Individual) Transfers to Another Facility," revised 04/2021, showed the hospital must provide an appropriate MSE beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) by qualified personnel as determined by the Medical Staff office Rules and Regulations when an individual presents to the ED and requests examination or treatment for a medical condition. A MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.

Review of the hospital's policy titled, "Medical Screening Exam (MSE)," revised 04/2022, showed current hospital and ED protocol will be followed for the disposition of psychiatric (relating to mental illness) or substance abuse (misuse of alcohol and/or other drugs) patients. When ancillary services of the hospital are necessary to complete the MSE, the ED and ancillary services will coordinate services to assure that an appropriate history and physical examination including testing is obtained and provided for all patients.

Review of the hospital's policy titled, "Admissions to the Emergency Department," revised 03/2019, showed no patient will be discharged from the ED without a thorough MSE by an ED physician or qualified personnel.

Review of the hospital's policy titled, "Mental Health Assessment," dated 12/2021, showed the ED physician or nurse completes their MSE. If the MSE indicates that a Mental Health or Substance Abuse Assessment is warranted, an order will be placed in the medical record and Behavioral Health Intervention (BHI) services will receive an order. The assessing Registered Nurse (RN) or attending physician must make the determination for psychiatric assessment. A Qualified Mental Health Professional (QHMP) would then assess the patient, discuss with the treating RN and the assigned physician.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 01/2022, showed a MSE will be provided for all patients requesting ED services by a Physician; a Physician Assistant (PA) with a supervision agreement with an ED physician; a nurse practitioner (Advance Practice Nurse) with a collaborative practice agreement with an ED physician; an ED RN certified in advanced cardiac life support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) who has access to an onsite ED physician.

Review of the hospital's undated document titled, "Lithium, Serum," showed serum lithium (a medication used in the treatment of certain psychiatric disorders) level tests were sent to another hospital for processing. Turnaround times for STAT (immediately) order results were reported within one hour of receipt in the laboratory. Rountine order results were reported within two hours after receipt in the laboratory.

Review of the hospital's undated document titled, "QMHP Master Schedule 2022," showed there were six QMHPs available during the time period Patient #4 was in the ED from 6:00 PM on 01/05/22 through 3:15 AM on 01/06/22.

Review of the hospital's undated document titled, "2022 Psychiatry On-Call Calendar," showed a Psychiatrist was on call from 01/02/22 through 01/10/22.

Review of Patient #4's medical record showed the following:
- He was a 33-year-old male who presented to the ED via EMS on 01/05/22 at 6:16 PM with a chief complaint of bizarre behavior and had stopped taking his lithium that day.
- He had a past medical history of schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real) for which he was prescribed lithium.
- He denied having thoughts of self-harm (behavior that is harmful or potentially harmful to oneself), suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death).
- Laboratory tests were ordered, but a lithium level was not ordered and a urine drug screen (UDS) was not collected. He did have a low potassium (a mineral needed for your body to function properly) level that was addressed with an oral potassium supplement.
- Staff M, PA, documented that Patient #4's behavior, thought content, and judgement were documented as normal.
- Multiple unsuccessful attempts were made to contact Patient #4's father over seven hours to evaluate whether Patient #4 was believed to have been a possible threat to himself or others. Contact was finally made with Patient #4's mother, who said that Patient #4 and his father argued a lot. Patient #4 was offered a ride home, but declined.
- An After Visit Summary, dated 01/06/22 at 1:25 AM, showed that Patient #4 was to continue taking lithium as previously prescribed.
- On 01/06/22 at 1:37 AM, Staff Z, RN, documented that Patient #4 was given his discharge instructions and follow-up care was reviewed. Patient #4 verbalized understanding and was stable.
- Patient #4 was discharged at 3:05 AM on 01/06/22.
- There was no mention in his medical record that either a QMHP or a psychiatrist was consulted for Patient #4.

Review of the hospital's undated incident report titled, "Current Summary," showed the reported event involved an alleged missing person (Patient #4) which was publicized on the local news. The event was reviewed extensively from a patient safety and regulatory perspective. No process breakdowns were noted. Patient #4 did have a psychiatric history, but it was assessed appropriately and he had decisional making capacity. The event was entered for documentation and was closed with no further action.

Review of the hospital's undated and untitled document showed a statement from Staff Z, RN. She was Patient #4's primary nurse. Patient #4 had said he was planning on going to a shelter. Staff Z had talked to Patient #4's mother, who indicated that it was not an option to have Patient #4 go stay with her. Since they could not get ahold of Patient #4's father, Patient #4 stated that he would take the bus to the shelter. Staff Z told him that she did not want him to take the bus because it was cold and she offered him a ride, but he said he would wait until morning to take the bus.

During a telephone interview on 03/14/23 at 4:30 PM, Staff W, Paramedic, stated that Patient #4 told them that he did not take his lithium because he did not like the way it made him feel.

During a telephone interview on 03/15/23 at 8:45 AM, Staff U, RN, stated that she was the triage nurse when Patient #4 was brought in by EMS. He was upset that his father had called EMS and that he had to be brought to the ED. His father had reported to EMS that he was acting bizarre. Patient #4 stated that he had just stopped taking lithium that day. He denied SI/HI and self-harm, and did not seem to be in a manic state. His belongings were collected by security, he was changed into paper scrubs, and a one-to-one (1:1, continuous visual contact with close physical proximity) sitter was initiated. Urine samples were usually part of the order system, but unless they were actively seeking placement, staff generally did not actively push to get a urine sample.

During a telephone interview on 03/14/23 at 1:47 PM, Staff M, PA, stated that he felt that he was holding Patient #4 against his will and there was no reason to hold him. Because he was not exhibiting any symptoms of psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) or SI/HI, he did not discuss Patient #4 with the attending physician prior to discharge. He did not remember why he did not order a lithium level. A urine drug screen was ordered but he did not know why it was not obtained. There was no barrier to get a psych evaluation and nothing in his presentation suggested psychosis.

During an interview on 03/15/23 at 9:30 AM, Staff D, ED Nursing Director, stated that the urine sample would have shown up in Patient #4's ED medical record timeline if it had been collected. He was medically cleared for discharge and offered a ride, but he declined the ride.

During an interview on 03/15/23 at 10:15 AM, Staff Y, Risk Manager, stated that after Patient #4 had discharged, he had gone missing. They were made aware of the situation by Patient #4's father, who had contacted them when Patient #4 had not shown up at the house. He was advised by Patient #4's case worker to file a missing person report.

During a telephone interview on 03/15/23 at 9:00 AM, Staff X, ED Medical Director, stated that if a patient was on lithium, in his opinion, a lithium level should be checked due to the very narrow therapeutic window and it was quite a dangerous drug. If lithium levels were not therapeutic, symptoms could include manic behavior, acting bizarre, or acting depressed. Lithium toxicity symptoms could range from no symptoms at all to lethargy, weakness, seizures, and electrolyte imbalances. He said that if a patient was not taking his lithium, he would consult with a QMHP to adjust or add new medications. Patients needed to be cleared medically before a QMHP consult could be placed. Medical clearance included vital signs, the patient's history, and labs such as a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), urinalysis (a laboratory examination of a person's urine), UDS, and blood alcohol level. QMHPs were available via telehealth 24/7. He would have involved a QMHP to help with adjusting or adding medications and asked to speak with a psychiatrist for more assistance with medication decisions. He would not make a decision on his own to change any psychiatric medications.

As of 03/15/23 at 4:30 PM, three attempts had been made to interview Staff V, Attending Physician. All attempts were unsuccessful.

As of 03/16/23 at 8:20 AM, three attempts had been made to interview Staff Z, RN. All attempts were unsuccessful.