HospitalInspections.org

Based on review of Emergency Department (ED) medical records, Facility #2 records and documentation, Facility #3 medical records, training records, trending report, interviews, and review of policy and procedures, the facility failed to comply with 489.24 regarding Patient #1, #2, #15, #17, and #21, five (5) of 21 patients reviewed.


Findings include:


Cross Refer to A-2407, 489.24 (d) for the facility's failure to ensure that necessary stabilizing treatment was provided for emergency medical and/or psychiatric conditions within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required stabilizing the medical and/or psychiatric condition for Patients #1, #2, #15, #17 and #21.

Based on review of Emergency Department (ED) medical records, review of Facility #2's records and documentation, review of Facility #3's medical records, interviews, training records, trending report, and review of policy and procedures, the facility failed to ensure the provision within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required for stabilizing the Emergency Medical Condition (EMC) and/or Emergency Psychiatric Condition for five (5) of 21 patients reviewed, Patient #1, #2, #15, #17 and #21.


Findings include:


MEDICAL RECORD REVIEWS/PERTINENT INTERVIEWS

PATIENT #1
Review of the ED record for Patient #1 revealed that this 19 year old (y/o) male presented to the ED via Emergency Medical Services (EMS) on 4/9/2015 at 2:35 a.m. with the chief complaint of psych (psychiatric)/behavioral crisis. Review of EMS notes revealed that the patient was picked up from his home. They were told by family (his aunt) he was staring off into the distance and talking to himself.
Review of Nurse's Notes revealed: "2:35 a.m. ...Acuity 2.
2:38 a.m. Psych: ...mood is elevated, Delusions are religious, states 'I am Black Jesus.' Affect is flat. 'Smoked a blunt (marijuana), don't remember the time but I'm good.'
3:06 a.m. Discharge ordered by physician (#1).
3:23 a.m. Haldol 10 mg IM (intramuscular) (antipsychotic). 3:24 a.m Benadryl 50 mg IM (antihistamine).
5:12 a.m. ED Rounding: Pt (patient) is being confrontational and not staying in his room. 5:50 a.m. continuing to try to come out into the hall."
At 7:47 a.m. contact was attempted by phone with his Aunt. Voice mailbox was full.
"8:54 a.m. Charge nurse informs sending pt to (Facility #2) via taxi. Pt given clothes. Unable to contact family. 9:09 a.m. Discharge instructions given to patient....Taxi voucher. Discharged to (Facility #2)."

Review of Physician #1 History and Physicial and ED notes revealed: "2:59 a.m. ...Prior diagnosis: schizophrenia... previous inpatient psychiatric history, discharged two days ago (4/6/2015) and is staying with aunt...not sleeping.
3:05 a.m. Does not meet admission criteria..."
Patient #1 was discharged (d/c'd) and left the ED on 4/9/2015 at 9:10 a.m. via taxi. D/C diagnosis: Schizophrenia.

There was no documented evidence of the patient's status at the time of discharge. There was no documented evidence of referral to Case Management or Social Services documented in the patient's ED medical record.


Interview with the Administrator of Facility #2 (homeless shelter) on 4/28/2015 at 9:25 a.m. revealed, "(Facility #2) is a day shelter for homeless adults. They can come here and do the same things that they would do in their homes... take showers, receive their mail. We have a computer lab and staff available to help them with resumes and search for jobs. They do not sleep here unless it is below 32 degrees outside. (Patient #1) was brought to our facility on 4/9/2015 by a taxi. He did not know where he was. He was received here heavily medicated and was like a six (6) year old. He only knew two (2) phone numbers. One was his Aunt and another family member. I called the Aunt and the voice mail was full. I called the other family member and was given two (2) more numbers. Eventually the Aunt returned my call. She said that she had called (Facility #1) and was told that he was not a patient there. She came here and picked him up."


During a phone interview on 5/5/2015 at 10:11 a.m. the Aunt of Patient #1 revealed that her nephew (Patient #1) was picked up from her home by an ambulance service on 4/9/2015. "When I came home from work in the middle of the night, I knew he needed help. He was staring off into space, pacing. He told me that he would see me in hell. I can tell when he needs help. I called an ambulance and asked them to come get him without the sirens and lights. I did not want to upset him. The next time I heard from him, I was getting a call from (Facility #2). The lady told me that they sent him in a taxi from the hospital. He was still heavily sedated. It was like putting a three year old in a car and sending them off. The lady from (Facility #2) told me that they (Hospital #1) always do this. He was still very confused. He urinated on himself twice and was delusional. I took him on over to (Facility #3) and he stayed there for about a week. I don't understand why they sent him out of the hospital (Facility #1) knowing that he needed treatment."


Review of Facility #3's (psychiatric inpatient facility) Medical Record for Patient #1 revealed that he presented to the facility on 4/9/2015 at 1:58 p.m. and was admitted with a diagnosis of Psychosis. Review of the Initial Clinical Assessment and Initial Psychosocial Assessment revealed, "Pt was D/C from (Facility #3) 2 months ago to his paternal aunt's custody. 2 days after D/C pt had reaction to medication. He went to (Facility #1) ...admitted there for 1 week... 3/27/15 the pt's aunt called 911 & (and) sent him to ER (emergency room)... D/C 1 week later. 4/2/15 pt left home & appeared be delusional. On 4/8/15 pt's aunt called 911 again, this morning she was given a call & told he was at (Facility #2). The hospital (Facility #1) told the pt's aunt that the hospital never received him although he has on a hospital bracelet. The pt has been (having) paranoid thoughts, involuntary movements. The pt may be having reaction to his medications."
"History and Physical: History of Present illness: Increased psychotic symptoms with delusions, bizarre behavior, and paranoia: tardive dyskenesia secondary to psychiatric medications. Impression: Tardive dyskinesia, secondary to psychiatric history, by history." Admission Psychiatric Evaluation: "...endorses auditory hallucinations... reports deterioration of hygeine, decreased energy withdrawal, isolation, difficulty falling asleep and staying asleep, hopelessness, tearfulness and feelings of worthlessness and flat affect." Review of a 4/10/2015 Therapist note revealed, "...The aunt does not know what happened at (Facility #1) because they did not call her and they sent the pt to a shelter..." Patient #1 was discharged on 4/17/2015 home to his aunt in stable condition.


Interview with Facility #1's Medical Director on 5/7/2015 at 9:30 a.m. revealed that he thought the discharge of Patient #1 on 4/9/2015 was appropriate and acceptable for this patient to follow up. When asked what the facility's process for contacting the family was he stated, "We do not have a certain number of times that we call. You don't get the feeling that the family wanted to be a part of the process, they (Patient #1's aunt) called an ambulance to get the patient, but never presented to the ER." When asked if he thought that the discharge of Patient #1 was appropriate he stated, "I think there should have been a description of the patient at the time of discharge. I can only ascertain that he was awake and alert. I would think this is a safe discharge. The case manager should have been involved to determine an appropriate place to discharge. Is it our responsibility to find every homeless patient that presents to the ER a home? It is our responsibility to assess, treat and consult psychiatry when appropriate."


During an interview on 5/7/2015 at 11:05 a.m. Psychiatrist #1 reviewed Patient #1's ED record for 4/9/2015. She stated that this patient did not meet criteria for admission. When asked if psychiatry should have been consulted she stated, "I'm not sure. He was just discharged two days earlier and was on a good dose of medications. I'm not sure what was going on that he was given Haldol and Benadryl. He was probably becoming an in-patient. It looks like they tried to arrange where he goes, and the Emergency Room doctor made a decision to discharge the patient. He probably came out into the hall pressuring staff to discharge him, it goes along with the illness." When asked if she thought that the discharge was appropriate, she stated, "It was several hours after the medications were given when the patient was discharged. It does not seem like he was drugged or sedated at the time of discharge." When asked if it was appropriate to discharge this patient to (Facility #2) Psychiatrist #1 stated, "All I know is sending someone to a shelter should be a last resort."


Facility #1 failed to ensure that necessary stabilizing treatment was provided for within the capabilities of the staff and facilities available at the hospital prior to discharging Patient #1 on 4/9/2015 to Facility #2, a homeless shelter. This patient was not homeless.


PATIENT #2
ED record review for Patient #2 revealed this 31 y/o female presented to the ED on 4/14/2015 at 9:45 p.m. via ambulance after she was found wondering in a restaurant parking lot confused. She was admitted with an Acuity Level 2 into the ED by Physician #3. Review of Nurse's Notes revealed: "21:46 (9:46 p.m.) ems states that she was wandering...acting confused. admitted to taking drugs and drinking today. admits to cocaine and alcohol... appears unkept. 21:49 (9:49 p.m.) Behavior is agitated, pt states her nerves are bad because she missed some medication." Psych 21:51 (9:51 p.m.) ...Mood is irritable... Patient is challenging, irritable... restless, affect is blunted... uses cocaine..."
Review of Physician #3's documentation revealed, "4/14/2015 21:54 (9:54 p.m.) he patient presents to the emergency department with paranoia, psychosis, auditory hallucinations...visual halluciations, has delusions, a history of abuse...cocaine. Onset: The symptoms/episode began/occurred 1 week ago... Past psychiatric history: addiction history, cocaine, depression, schizophrenia... Not taking her meds. ...Has experienced similar episodes in the past, chronically..." "21:56 (9:56 p.m.) Behavior/mood is anxious, aggressive. Affect is animated... Patient having thoughts of suicide." "21:58 (9:58 p.m.) Differential diagnosis: drug withdrawal, acute psychotic break, depression, psychosis secondary to non-compliance..." Patient #2 was given Ativan 2 mg IM (anxiety) on 4/15/2015 at 2:24 a.m. 6:47 a.m. the Interim Medical Director (Physician #1) documented "held in the ER awaiting psych disposition as entire city is on diversion. My exam at this time shows patient awake and alert. No overt psychosis. Discharge to (Facility #2)." Discharge instructions included, "Take your medicine. See (county) Behavioral Health." "8:05 a.m. Discharged to a shelter." Patient #2 was sent to Facility #2 via taxi on 4/15/2015 at 8:05 a.m.


Review of a copy of the taxi voucher given to Patient #2 by Facility #1 confirmed she was sent to Facility #2.


During an interview on 5/7/2015 at 9:45 a.m. the Hospital Medical Director reviewed the ED record for Patient #2 and stated that the hospital was on psychiatric diversion the day that this patient was treated (4/14-15/2015). When asked if he thought that a Psychiatric consult would have been appropriate, he stated, "She had no advert psychosis. I don't think she would have been an appropriate admission."


During an interview with Psychiatrist #1 on 5/7/2015 at 11:20 a.m. the ED record for Patient #2 was reviewed and discussed. When asked if due to this patient's status when admitted to the ED should a Psychiatrist have been consulted she stated, "A consult for Psych could have been made. I am not sure why we were not consulted." She revealed that a psych consult could and should be made even if the hospital was on psych diversion. When asked about Patient #2's discharge Psychiatrist #1 stated, "I see this patient was sent to (Facility #2) again. We are going to work on exhausting all other options before we send a patient to a shelter..."


Facility #1 failed to ensure that necessary stabilizing treatment was provided for within the capabilities of the staff and facilities available at the hospital prior to discharging Patient #2 on 4/15/2015 8:05 a.m. to Facility #2. This patient had suicidal ideation at 9:56 p.m. on 4/14/2015 which was never addressed.




PATIENT #15
Review of Patient #15's ED medical record revealed that this 31 y/o male presented via ambulance to the ED of Facility #1 on 3/15/2015 at 9:16 p.m. and was admitted as an Acuity Level 2 by Physician #4. Review of the EMS documentation revealed: "...ALOC (altered level of consciousness) secondary to crystal meth (methamphetamine) use...acting paranoid stating that people had shot at him and he ran away from them...stated he had done '2 bowls' of crystal meth, smoked and injected approximately 2 hours prior...kept trying to slide down and off stretcher to hide while enroute... "
Review of Nurse's Notes revealed: "9:17 p.m. ...Behavior is anxious, restless, uncooperative... awake, confused...
9:33 p.m. Ativan 1 mg IVP (anxiety).
10:15 p.m. Appears agitated...restless
10:31 p.m. ...combative... aggressive and non-compliant, pt ran from ed, staff pursued and apprehended pt by security and placed in restaints, pt mumbling incoherently...10:31 p.m. Ativan 2 mg IM.... Geodon 10 mg IM (symptoms of schizophrenia). ..Patient was restrained with limb restraint, soft wrist restraints to bilateral wrists. Patient's behavior is uncooperative, anxious, more agitated.
3/16/2015 1:28 a.m. Restraints were removed due to decreased agitation/hostility, decreased confusion...
2:25 a.m. ....Patient's family has been updated over the phone... pt to stay in ed till am and then attempt to find placement in a halfway house.
4:18 a.m., 5:05 a.m. and 5:22 a.m. ED Rounding... Patient does not have any family members to update.
5:51 a.m. Discharge ordered by MD.
5:52 a.m. pt able to stand with assistance but unable to take steps..reported dizziness after standing..
6:50 a.m. and 7:38 a.m. Patient does not have any family members to update.
8:14 a.m. ED Rounding: Patient's family has been updated over the phone... Assisted patient to sit on side of bed, pt states became very dizzy, Pt drowsy...
8:45 a.m. ED Rounding: Pt stands and ambulates well... Discharged to home ambulatory. Follow up with private physician as needed."
Patient #15 was discharged from the ED on 3/16/2015 with a taxi voucher. Review of a copy of the taxi voucher given to the patient revealed that it had the address of Facility #2 documented on it.



There was no documented evidence that the facility consulted with their Social Worker or Case Manager regarding getting this patient admitted to a halfway house or back to the halfway house he was living in. Several places have documentation that the family was updated. Other documentation stated there was no family to update.


During an interview with the Medical Director on 5/7/2015 at 9:30 a.m. the ED record for Patient #15 was reviewed. When the Medical Director was asked if there was appropriate treatment during this ED visit to stabilize this patient, he stated that there was. When asked whether or not this was a safe discharge, he stated, "There is no way that you are going to get Meth users accepted into a halfway house. This patient was safe for discharge."



During an interview on 5/7/15 at 12:50 p.m. Psychiatrist #1 reviewed Patient #15's ED medical record. When asked if in her opinion, she thought that this patient needed a psychiatric consult while in the ED, if she thought treatment in the ED was appropriate and if she thought that the discharge was appropriate, she stated, "I think because of the level of acuity, they could have consulted the Psychiatrist. This patient could have been a candidate for inpatient care. This is someone that stayed a long time in the ED and required restraints. His behavior was not recorded. I think it was substance abuse, and many times the symptoms go away. He became dizzy before he was discharged. I think that this would be an instance that the ED physician would need to reach out to the Psychiatrist to evaluate and assess the patient. We don't have documentation about placement options being exhausted. We are working on Case Manager and Social Worker being consulted for placement of the patient prior to discharge."


Facility #1 failed to ensure that necessary stabilizing treatment was provided for within the capabilities of the staff and facilities available at the hospital prior to discharging Patient #15 on 3/16/2015 to Facility #2.



PATIENT #17
Review of the ED medical record for Patient #17 revealed that this 41 y/o male presented to the ED on Tuesday 3/24/2015 at 1:12 a.m. as a walk-in complaining of shortness of breath (SOB) with cough and congestion since the previous night. The patient stated he was a dialysis patient and had missed his dialysis treatment on Friday, 3/20/2015 and complained of "pain all over." The patient was admitted by Physician #5 as an Acuity Level 2 with a history of Hypertension, HIV and End Stage Renal Disease. At 3:38 a.m Critical Lab Values were reported: Creatinine 9.6 (reference range 0.6 - 1.3) and Platelet count 34 (reference range 150-430). Multiple other abnormal lab values were noted as reported: WBC 2.4 (reference range 4.0-11.0); Hemoglobin 8.0 (reference range 13.3-17.3); Hematocrit 24.2 (reference range 39.1-51.0); Total Protein 8.9 (reference range 6.4-8.2); BUN 72 (reference range 7-18). AN EKG was done and documented as abnormal. A chest xray showed mild fluid overload. There was no documented evidence of any dialysis treatment was offered or given to Patient #17 while in the ED. At 4:45 a.m. the physician wrote an order for discharge. He was discharged from the ED on 3/24/15 at 4:53 a.m. with discharge instructions "see your nephrologist today for a time to get dialyzed."


Review of a copy of the taxi voucher given to Patient #17 revealed that he was sent to Facility #2 at discharge.


During an interview on 4/30/2015 at 2:20 p.m. the CNO stated that their hospital does not offer dialysis on an outpatient basis. "The hospital provides dialysis to in-patients." When the CNO was asked about Patient #17 she stated, "Yes, I reviewed this medical record. I'm not sure why he was sent to (Facility #2) instead of his dialysis treatment center."


Interview with the Emergency Room Charge Nurse on 5/1/15 at 10:30 a.m. revealed that Facility #1 has a dialysis unit. When asked if the hospital offers dialysis, he stated that they do. "If a patient needs to be dialyzed, we can take them upstairs to our dialysis unit to have them dialyzed."


Review of the facility's "Contracted Clinical Services - 2015" document revealed that they had a contract with a local Dialysis Vendor who "Provides oversight of hemo-dialysis treatment for patients. Qualified to administer dialysis treatments and clinically manage patients with chronic renal failure ..."


During an interview with the Medical Director on 5/7/2015 at 10:00 a.m. the ED medical record of Patient #17 was reviewed. The Medical Director stated that he thought this was an appropriate discharge. "This is a dialysis patient that missed his treatment. The ER is an outpatient service. We are not in the business of providing outpatient dialysis to patients." When asked if (Facility #2) was the appropriate place to send this patient at discharge, he stated, "I have no idea why the ER doctor chose to send him there. I don't think it would have been a bad idea for them to call the dialysis center."


Facility #1 failed to ensure that necessary stabilizing treatment was provided for within the capabilities of the staff and facilities available at the hospital prior to discharging Patient #17 on 3/24/2015 to Facility #2, a homeless shelter.



PATIENT #21
Review of the ED medical record for Patient #21 revealed that this 39 y/o female presented on 4/14/2015 at 1:30 p.m. via EMS. Review of EMS documentation revealed, "...police and fire on scene...care home personnel stated that pt was yelling and threatening other residents, has not been taking her medication, and has been unruly.... having visual and auditory hallucinations en route to ER and shooting out the back windows with her fingers, both barrels..."
Review of Nurse's Notes revealed: "1:51 p.m. EMS states that they were called to personal care home (PCH) d/t (due to) pt hearing voices and having visual hallucinations. Pt states she smoked spice 2 days ago... Appears unkept. Behavior is inappropriate for age.." She was admitted to the ED with an Acuity Level 2.
Review of ED Physician #2's History and Physicial and ED Course documentation revealed: 4/14/2015 3:26 p.m. The patient presents to emergency department with psychosis, has experienced auditory hallucinations... visual hallucinations... prior diagnosis: bipolar disorder, Schizophrenia... has experienced similar episodes in the past, several times... has been recently seen at (Facility #1) ED, this week, for similar complaints... Pt has been hostile and combative at several different group homes per our social worker who has placed her at several... (Haldol 10 mg IM was given at 6:58 p.m.)
7:55 p.m. ED Course: I have made (Psychiatrist #1) aware of the patient but we have no psych beds currently. Will ask social work to work on finding us a bed to refer to. All (city) hospitals are currently on diversion. 11:35 p.m. ..patient is confabulatory and cannot be easily believed as her story keeps evolving. No psych beds are currently available. She has been evaluated by (psychiatric facility) and they do not yet feel she is a candidate for admission. We will keep her on admit hold pending further evaluation and hopefully an opening for a bed here." 4:32 a.m. Attending physician now Physician #3. 5:57 a.m. Attending physician now Physician #1. "6:54 a.m. Nurse to call PCH to determine circumstances of being sent here being this is prolonged ER hold for psych..."
Documentation in the Nurse's Notes dated 4/15/2013 7:11 a.m. stated, "Nursing Supervisor called (a regional health center in the south of the state) about this pt and said we can send the paperwork and she will see what they can do for us.... Now waiting on them to contact us." 8:53 a.m. "Called (contact at regional health center) and she is getting ready to discuss the pt with the doctor. Will give a call back..." There was no further documentation regarding this facility.
Patient #21 was discharged from the ED on 4/15/2015 at 10:48 a.m. by Physician #1 with discharge instructions to follow up with a behavioral center in 1-2 days. There was no documented evidence Patient #21 signed the discharge instructions.
Review of a copy of the Taxi Voucher given to Patient #21 on 4/15/2015 revealed that she was sent to Facility #2, a homeless shelter, via taxi.


During an interview with the Hospital's Medical Director on 5/7/15 at 11:40 p.m. the ED medical record for Patient #21 was reviewed. The Medical Director stated that the hospital gets patients from PCHs that they do not want. When asked, in his opinion, did the patient need a psychiatric consult, he stated, "It sounds like the patient was hostile and combative at the group home. The patient does not appear to be actively schizophrenic. At some point, the ER doctor deemed that she was medically stable to go home. Going forward, if the patient was going to be admitted, and the ER deems them medically stable, the psychiatrist will have to evaluate for discharge."


On 5/7/15 at 12:40 a.m. an interview was held with Psychiatrist #1 and the Quality Manager. Patient #21's ED chart was reviewed. When Psychiatrist #1 was asked if this patient needed a Psychiatric consult, she stated, "Yes, the patient required a consult. This patient needed to be admitted. This is one of the patients that could have been followed up on by us in the a.m." When asked if in her opinion the discharge was appropriate, she stated, "She was discharged at 10:15 a.m. I don't know if she was aggressive or calm. We could have consulted again and it could make a difference." When asked if appropriate care was given to this patient in the ED, she stated, "I don't see progress at different times. I don't see documentation of her progress."
The Quality Manager stated, "That is part of our new process that we have in place. If the patient was intended to be admitted, the Psychiatrist will have to see the patient prior to the discharge." Psychiatrist #1 stated, "I think that one thing we are putting in place is that we exhaust all options before standing to homeless shelter. A Personal Care Home would have been a better option."


Facility #1 failed to ensure that necessary stabilizing treatment was provided for within the capabilities of the staff and facilities available at the hospital prior to discharging Patient #21 on 4/15/2015 to Facility #2, a homeless shelter.




OTHER INTERVIEWS

On 4/28/2015 at 10:45 a.m. an intrance interview was held with the Assistant Administrator, Chief Operating Officer (COO), Chief Nursing Officer (CNO) and the Quality Officer. The CNO related that their Patient Advocates and their Chief of Medicine were currently reviewing discharges from the ED. When asked how it is determined where a homeless patient is to be sent after discharge and if their hospital had an agreement or contract with homeless shelters the CNO stated, "A Homeless Resource Guide is used.... the Case Manager would know more about that. There is no agreement or contract." The CNO also stated the facility had no policy regarding discharging the homeless population. During the interview the Chief Operating Officer (COO) stated, "All Travel Vouchers have to be approved now."

On 4/28/2015 at 2:40 p.m. the CNO stated that the hospital had stopped sending patients to Facility #2 when an article was published in the area newspaper. "The CEO (Chief Executive Officer) and COO met with the Administrator of (Facility #2) on Tuesday after the article was published. We then realized that (Facility #2) was not what we thought it was. We thought they had case management available and would get these people to homeless shelters. The homeless shelters are not open during the day." When asked how the decision was made about where they were to discharge homeless patients to from the hospital the CNO stated, "The Homeless Resource Manual is utilized. I was told by the case manager that it was given to her in 2010, but she was not sure where it originated from. We also stopped giving cab vouchers without oversight. The Assistant Administrator oversees this." During the interview the CNO was asked about how the facility provides care for psychiatric patients and how they admit a patient to the psychiatric unit from the ED. She stated, "On the 6th floor we have an acute adult psyciatric unit with 47 beds. The ED physician has to consult the psychiatrist and he has to accept the patient for admission to the psychiatric unit. There are standardized testing that is done on psych patients presenting to the ED."

On 4/28/2015 at 4:02 p.m. the Case Manager Director for the ED was met with. She stated that she has two (2) Case Managers that work under her, but there is no coverage at night. When asked to explain what her and her staff are responsible for in the ED she stated, "We do assessments to make sure patients are receiving every thing they need. We also start discharge planning." When asked who decides where homeless patients and psychiatric patients are sent when discharged she stated, We have a resource guide for homeless shelters that we use. When the doctor has deemed the patient stable for discharge we try to locate family. When all avenues are exhausted we then send them out to whatever destination they choose. If they choose to go back to the street we discharge them." She revealed that she was not aware of any contracts that the hospital had with any shelters.


On 4/28/2015 at 4:30 p.m. the Quality Officer revealed that their hospital had no policies or procedures specifically for psyciatric or homeless population.


Interview with the Assistant Administrator on 4/29/2015 at 10:19 a.m. revealed that he was aware of the Community Resource Guide that was used when sending patients to homeless shelters. When asked if it had been adopted and approved by the hospital he stated, "I'm not sure on what process they used to implement that." At 10:26 a.m. he stated, "I talked to (the Case Manager Director of the ED) and she said that the Resource Guide had not went through the process of approval of the hospital. It was received from an outside source."


On 4/30/2015 at 2:48 p.m. the ED Director stated that the hospital had two (2) Patient Advocates who take care of complaints for the ED. When asked to explain the process for the discharge of homeless persons that were seen in the ED she stated, "We treat them in the ED and when they are discharged we contact the case manager who gets them to a shelter."


On 4/30 2015 an interview was held with Patient Advocate #1 and #2. Patient Advocate #1 stated that their job was to see in-patients and ED patients and respond to patient complaints. When asked if they were aware of a recent complaint about a patient sent to a shelter without adequate clothing Advocate #2 stated that he had spoken to the patient's aunt about her concerns. "She said that the patient was sent to the shelter without adequate clothing. What he had on was given to him by the shelter. She said that his medication had been too strong and he was still medicated after being sent to the shelter. She said that she was home and did not know why she was not contacted to come and get him. She told me that she had called the hospital and was told that he was not a patient in the ED and the call was transferred to the Behavioral Health Unit. She said they could not give her any information and was very abrupt to her." He denied knowing of any other complaints regarding patients being discharged to shelters.


During an interview on 5/1/2015 at 8:40 a.m. Staff Nurse #1 was asked about treatment of psychiatric and homeless patients in the ED. She stated, "Many of the psychiatric patients are admitted upstairs. The ones that are not admitted are held in the ED until the case manager arrives and suitable arrangements are made." When asked who makes the determination as to where the patients will be discharged she stated, "The charge nurse and the case manager make this decision for ER patients. I can't think of any dangerous patients that we have sent (to shelters). We try to contact the family and then we go through the case manager. We don't just kick them to the curb. We hold them in the ER until we have a bed or transfer them to another facility. We are going through the Nursing Supervisor now. We no longer send patients to (Facility #2)." She was asked if patients are sent to other shelters and stated, "I am not aware of other shelters." When asked if psychiatric patients are discharged while remaining under the effects of medication or if patients that present to the ED requesting help for drug or alcohol detoxification are discharged while still inebriated she stated, "No, we would keep patients until the effects of the medication wore off. We never discharge a patient that is intoxicated or under the effects of drugs without a responsible adult, and then they are referred to Behavioral Health."


During an interview on 5/1/2015 at 8:55 a.m. the Interim ED Medical Director (Physician #1) stated that the facility had two (2) psychiatrists on staff, with call coverage 24/7. "We have a large psychiatric floor with 47 beds available. Sometimes we are on psychiatric diversion. If one of the physicians is sick, only one doctor cannot care for 47 patients." When he was asked about the homeless population of psychiatric patients seen in the ED and being sent to shelters he stated, "The homeless come in with vague complaints. Usually they need a place to stay. We try to find them a place to stay. We let the Case Manager know, and we try to send them to a shelter. When homeless psychiatric patients come in we evaluate them, but if they do not meet admission criteria we keep them until daylight hours and have Case Management assist with placement." When asked if inebriated patients are sent to discharge he stated, "If you are referring to the patient that was in the (area newspaper), I tried to get him to call someone to come get him." Physician #1 was asked if he thought if was appropriate for an intoxicated person, that was not homeless and had a car in their parking lot, to be sent to a day shelter for homeless in a taxi from their ED. He stated, "We send patients to (Facility #2) when the patient needs more resources than what the hospital can provide. We do not want to discharge these patients to the street. We were told by the case m