HospitalInspections.org

Based on medical record reviews, facility documentation reviews, and interviews, the facility failed to do the following on one (Patient #1) of 20 patient records reviewed:
1. Perform and document an appropriate medical screening examination (MSE).

2. Provide documentation of/provide evidence of orders for a Behavioral Health or Psychiatry consult on a patient with a psychiatric emergency medical condition.

3. Follow its Bylaws to manage an emergent situation in which a patient was in imminent danger and delayed administering appropriate interventions (i.e.: restraints or seclusions) or treatments (i.e.: emergency psychiatric medications) that could have reduced the risk of danger.

The findings included:

Medical Record Reviews
4. Patient #1's medical record review at Facility A revealed the following:
Patient #1 arrived at Facility A on 07/23/2023, at 2:41pm via emergency medical services (EMS).

The Emergency Department (ED) Nursing Notes on 07/23/2023 at 2:41pm, Patient #1 verbalized the intent to kill
her mother and expressed homicidal ideation several times during her transport to Facility A.

The ED Nursing Notes on 07/23/2023 at 2:44pm noted Patient #1 to be verbally abusive with Security and Staff, pacing the hallway, speaking loudly, and stating she did not want to be here (at Facility A).

The ED Nursing Notes on 07/23/2023 at 2:50pm that Facility A's ED nurse (Staff #14) dialed 911, reached the Arlington Police Department, spoke to the dispatcher (badge #D2374), and "informed them of the situation". Staff #14 noted that police officers arrived with crisis prevention officers on 07/23/2023, at 3:00pm.

Facility A's treating ED Physician (Staff #10) began a medical screening on 07/23/2023, at 3:09pm. Documentation by Staff #10 notes the following:
Patient #1 was brought in with homicidal ideation, and family concerns that Patient #1 was trying to kill her mother and was brought in for further management and treatment. Staff #10 notes that Patient #1 exhibited pressured speech, anxiety, and agitation, was using verbal abuse and aggression toward staff, and was "laying on the floor in the hallways surrounded by police", but had no medical complaints. Staff further noted that Patient #1 was escorted from the ED with (Police Department).

On 07/23/2023, at 3:24pm, Facility A's ED nurse (Staff #15) noted that (Police Department) and Behavioral Health took custody of (Patient #1) for being verbally violent and aggressive toward staff and that Patient #1 was "escorted from the ED with (Police Department)".

There was no documentation found during the medical record review of Patient #1's medical record at Facility A that a Behavioral Health or Psychiatry consult was ordered or performed for Patient #1.

On 07/23/2023, at 3:29pm, Staff #11 documented, "She (Patient #1) refuses any treatment and continues to be uncooperative" and that he was "made aware of behavioral health unit decision to take pt (Patient #1)". Facility A documented that Patient #1 "left AMA (against medical advice) in police custody on 07/23/2023, at 4:29pm.

5. Patient #1's medical record review at Facility B revealed the following:

Upon her arrival on 07/23/2023, at 4:25pm during his MSE, Facility B's ED Psychiatry Physician's Assistant (PA) (Staff E5) recognized and noted that Patient #1 did not have the "capacity to understand the nature and consequences of a proposed treatment ....and make a decision whether to undergo the proposed treatment ....for medical decision making ..." and ordered psychoactive medications to be given during a psychoactive emergency.

Patient #1 was admitted to observation by Facility B's Staff #5 on 07/23/2023, at 4:32pm, pending stabilization of the psychoactive emergency and prior to transferring care to a psychiatric facility.

On 07/23/2023 at 4:49pm, Facility B's ED RN noted giving Patient #1 Emergency Medications (Haldol 5mg, Ativan 2mg, and Benadryl 50mg intramuscularly (IM)) for aggressive behavior that included posturing toward staff and officers, verbal threats to staff and officers, and the inability to redirect. Assault, Elopement, and Suicide precautions were initiated, Patient #1 was placed in seclusion, and patient monitoring every 15 minutes began. It was noted that less restrictive interventions were attempted by verbal de-escalation, offering alternative quiet areas, and offering oral (PO) medications. Patient #1 was assessed for injuries, and none were found.

Per physician notes on 07/23/2023 at 4:32pm by Facility B's Psychiatrist (Staff #5), Patient #1 arrived "on a DW (detention warrant) for agitated behavior and homicidal ideation" with a "manic or intoxicated appearance".

Patient #1 received Psychiatric Emergency Medications three more times (on 07/23/2023 at 5:58pm, and 10:41pm and on 07/24/2023 at 12:29am) within this ED chart review and ultimately was admitted to the Psychiatric Unit under an OPC obtained on 07/24/2023 at 8:50am at Facility B where she remained until 08/07/2023.

Policy Review
6. Facility A's "Medical Staff Bylaws, last reviewed and effective on 03/24/2021", stated on page 41:
" ...4.6. CARE IN AN EMERGENCY
...
4.6.2. Emergency Defined. For purposes of this Section, an emergency is defined as a condition in which serious or permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger ..."

Facility A's Bylaws were not followed regarding Patient #1's care in that Facility A's staff failed to manage an emergent situation in which a patient was in imminent danger and delayed administering appropriate interventions (i.e.: restraints or seclusions) or treatments(i.e.: emergency psychiatric medications) that could have reduced the risk of danger to Patient #1 or others and allowed completion of the MSE.
..."

7. Facility A's "Medical Screening Examinations and Patient Transfers Policy, last reviewed and effective on 10/07/2022, stated on page 5:
" ...4.1.5 Evaluating the patient and performing a Medical Screening Examination.
a. Evaluation. Each patient who arrives at the Hospital ED or Labor and Delivery will be evaluated by a physician or Qualified Medical Personnel (in the ED or Labor and Delivery as applicable) or evaluated by a physician on the medical staff who is on call and:

1) is physically able to reach the patient within a reasonable time, not to exceed 30 minutes, after being informed that a patient is present at Hospital and who requires immediate medical attention; or ..."

and on pages 22 and 23:
" ...5.10 Medical Screening Examination - Means the process to determine, with reasonable clinical confidence, whether the patient is suffering from an Emergency Medical Condition. Depending on the individual's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic tests or procedures. A medical screening exam is not an isolated event, but an ongoing process.

5.11 Qualified Medical Personnel or Qualified Medical Person
5.11.1 Emergency Department. In the Emergency Department, "Qualified Medical Personnel" means a physician on the medical staff or advanced practice professionals on the allied health staff of Hospital ....

5.11.3 Behavorial Health. In the Behavorial Health environment, "Qualified Medical Personnel" means either a member of the medical staff of Hospital or other licensed members of the behavioral health team to include Psychologists (Ph.D., PsyD), Registered Nurses, Master's prepared Social Workers (LCSW, LMSW), Licensed Professional Counselor (LPC, LPC Intern), and Licensed Marriage and Family Therapist (LMFT, LMFTA). Each Psychologist, Registered Nurse, Social Worker, Licensed Professional Counselor, or Licensed Marriage and Family Therapist who serves as Qualified Medical Personnel shall have received training on what constitutes an appropriate Medical Screening Exam ..."

Website and Additional Documents Reviews:
8. A website review revealed that Facility A advertises under the heading "Behavioral Health" that 'Inpatient Psychiatric Services' and 'Intensive Outpatient Programs, to include Mental Health Care' are provided.

9. During this investigation, Facility A was asked to complete a list of services that was provided to them. On that document, Facility A listed the following:

Psychiatric - Emergency
Psychiatric - Child/Adolescent
Psychiatric - Adult Inpatient
Psychiatric - Outpatient

Interviews
10. On September 11, 2023, at approximately 3:00pm, Facility A's Senior Director of Outcomes Management (Staff #1) was asked if the facility had or had requested a Detention Warrant (DW) or an Order of Protective Custody (OPC) and if she could provide the name of the police officer or documentation from the police officer that removed Patient #1 from the facility.

Staff #1 replied that the facility had not requested either a DW or an OPC and that the staff could not identify the police officer who had removed Patient #1 from the facility.

Based on medical record reviews, document reviews, and interviews, for one of 20 patients whose records were reviewed (Patient #1) Facility A failed to:

1. Provide a memorandum of transfer (MOT) for an appropriate transfer to an inpatient psychiatric treatment facility after the patient's medical screening examination determined Patient #1 had an acute psychoactive emergency medical condition requiring a transfer.
2. Notify the receiving hospital, Facility B, of Patient #1's transfer or secure an accepting physician.
3. Follow its policy when a signed or witnessed Patient's Request/Refusal/Consent to Transfer Form or a Leaving Hospital Against Medical Advice Form was not found during Patient #1's record review; no documentation could be found that Facility A had contacted the receiving facility's "Logistics Center" (the call center utilized to arrange transfers) regarding the transfer or to arrange a transfer through the Behavioral Health Transfer Coordinator (BHTC) for Patient #1 per its policy.

Findings included:
Record Reviews:
4. A review of Patient #1's medical record review at Facility A found the following:
It was documented by Staff #14 on 07/23/2023 at 2:44pm that Patient #1 was pacing in the hallway, speaking loudly, and was verbally abusive toward staff and security. On the same date at 2:50pm, Staff #14 documented that she called APD to assist with Patient #1.
Patient #1 was experiencing homicidal ideation (HI) when Staff #11 (ED Physician) documented in the "History of Present Illness" on 07/23/2023 at 3:09pm that Patient #1 presented with "HI that started just prior to arrival at the (emergency department) ED". Further documentation by Staff #11 stated that Patient #1 "was trying to kill her mother" and that "vitals were unable to be obtained due to the patient's violent nature" .... "Limited HPI (History of Present Illness) given pt's uncooperative behavior ..."

There was further documentation by Staff #11 within the "Final Medical Decision Making (MDM) Notes that Patient #1 "plans to harm her mother"... and was "Uncooperative here in the ED; patient found laying in the hallway surrounded by police and adamantly refusing treatment here" ... "Ultimately, Arlington PD and BHU (Behavioral Health Unit, a part of the Arlington Police Department) took custody...given her verbal abuse and aggression toward staff here."..."Pt escorted from the ED with APD."

The APD Officer (Other Staff #3) that responded to the 911 call from Facility A's Staff #14 stated in a follow-up interview on 09/26/2023 at 5:25pm that he had been called due to Patient #1's violent behavior and concern for the safety of Facility A's staff. Other Staff #3 stated that Patient #1 was arrested under a PSR (Public Safety Risk) and Order of Protective Custody (OPC) to protect the staff at Facility A. Other Staff #3 also stated that he felt Patient #1 was at risk of harming the staff at Facility A, stating, " ...It was going to get real bad real quick if I didn't remove her (Patient #1) immediately."

A signed or witnessed Patient's Request/Refusal/Consent to Transfer Form or a Leaving Hospital Against Medical Advice Form was not found within Patient #1's medical record.

There was no documentation that Facility B had been contacted by Facility A for the transfer of Patient #1 found within the chart review.

There was no MOT for Patient #1 found and Facility A failed to secure a transfer by phone to the receiving facility, Facility B, based on Patient #1's record review for both Facility A and Facility B.

No documentation could be found that Facility A had contacted the facility's "Logistics Center" regarding the transfer of Patient #1 per its policy.

No documentation could be found that Facility A had arranged a transfer for Patient #1 through the BHTC per its policy.

5. Patient #1 arrived at Facility B on 07/23/2023 at 4:25pm. While still in the ED, Patient #1 received Psychiatric Emergency Medications four times (on 07/23/2023 at 4:25pm, 5:58pm, and 10:41pm and on 07/24/2023 at 12:29am) within this ED visit and ultimately was admitted to the Psychiatric Unit with a diagnosis of "Severe manic bipolar I disorder with psychotic features" under an Order of Protective Custody (OPC) obtained on 07/24/2023 at 8:50am at Facility B where Patient #1 remained until 08/07/2023.

Policy Reviews:
6. Facility A's "Medical Screening Examinations and Patient Transfers Policy, last reviewed and effective on 10/07/2022, stated on page 4:
" ...4.1.4 Forms to fill out when patient refuses further exam or treatment. Any patient who refuses further exam and treatment or refuses to be transferred shall be asked to sign either a Patient's Request/Refusal/Consent to Transfer Form or a Leaving Hospital Against Medical Advice Form, which must be witnessed by the attending physician or other appropriate personnel and placed in the patient's medical record ..."

7. Facility A's "Medical Staff Bylaws, last reviewed and effective on 03/24/2021", stated on page 41:
" ...4.6.2. Emergency Defined. For purposes of this Section, an emergency is defined as a condition in which serious or permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger ..."

8. Facility A's Direct Admits and Transfers into and out of a (Facility A) Policy, last reviewed and effective on 06/02/2023, stated on page 1:
" ...3.2 Transfers and Direct Admissions for Behavioral Health Services. Transfers and direct admissions of patients that require behavioral health services will be routed through the BHTC (Behavioral Health Transfer Coordinator) ..."

and on pages 9 and 10:
" ...4.2.4 Physicians' responsibilities a. The transferring physician shall perform a Medical Screening Exam before any transfer is initiated. (See Section 4.1.5 and 5.10.) ...

4) Prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care. The transfer should minimize the risk to the patient ...

7) Complete the Physician Certification on the Memorandum of Transfer (MOT), prior to transfer. Completion of this form involves completion of the following 3 sections:
i. Patient Condition - check only 1 of the 3 listed patient conditions.
ii. Transfer Requirements - the physician completes section regarding Reason For Transfer (or provides the information to hospital personnel for completion). Other options are completed by the nursing unit personnel, e.g., Social Worker, RN, or Unit Secretary.
iii. Physician Certification - the physician summarizes the risks and benefits of transfer ..." and on page 12:
" ...4.2.5 Hospital responsibilities
a. Arranging for transportation. Transportation services for patient transfers will be coordinated by nursing or social work personnel upon the transferring physician's order. The appropriate mode of transportation shall be identified by the attending physician, and arrangements for transportation services will be discussed with the patient or responsible party. When necessary, Hospital will arrange for patient transfer by ambulance,using local fire department resources or private ambulance company...
b. Providing medical records to the receiving hospital. Hospital will send to the receiving physician and receiving hospital, with the patient, a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient ..."

Interviews:
9. On September 11, 2023, at approximately 3:00pm, Facility A's Senior Director of Outcomes Management (Staff #1) was asked if the facility had or had requested a Detention Warrant (DW) or an Order of Protective Custody (OPC) and if she could provide the name of the police officer or documentation from the police officer that removed Patient #1 from the facility. Staff #1 replied that the facility had not requested either a DW or an OPC and that the staff could not identify the police officer who had removed Patient #1 from the facility.

10. On September 12, 2023, at approximately 12:30pm, Facility A's Senior Director of Outcomes Management (Staff #1) was asked if there were any other documents to support Patient #1's medical record she could provide.

No further documents were provided.