HospitalInspections.org

Based on review of hospital policies and closed patient medical records, the hospital arranged the transfer of five patients (# 1, 2, 4, 5 and 20) prior to providing stabilizing treatment within the capabilities and capacity of its inpatient psychiatric unit and on call psychiatrist out of 20 patients selected for review from November to December 2011.

Findings included:

1. Review of hospital policy, "EMTALA: Medical Screening Examination and Stabilization Policy" dated November 2011, defined a patient as stable when the physician treating the emergency has determined that the EMC that caused the individual to seek care in the ED is resolved.

2. Review of hospital policy, "Admission to 7W - Criteria and process" dated 06/05/11, specified the capabilities of the inpatient psychiatric unit located on the 7th floor included the following:
-Age 18 to 65 years with psychiatric problems;
-Patients with suicidal ideation or attempt;
-Patients with physically aggressive threats or actions due to a treatable primary psychiatric condition;
-Patients with inability to care for self due to primary treatable psychiatric condition;
-Patients with significant impairment in social, familial, or occupational relations.

3. Review of a closed medical record revealed Patient # 1 presented with family to the emergency department on 11/10/11 at 11:43 AM after threatening self harm. Staff J, a Licensed Professional Counselor examined Patient # 1 (time unknown) and documented at 4:02 PM that Patient # 1 appeared confused, obsessively checking own sense of reality, had difficulty distinguishing between what was real and what was a dream, cooperated with the exam on behalf of the spouse but then claimed the spouse was "not really my" spouse. Further documentation revealed Patient # 1's spouse found a letter saying "I'd kill myself, but I am too chicken " and that the patient had attempted suicide 20 years ago. Review of the nursing notes revealed arrangements were made to transfer Patient # 1 to Hospital B. ED nurse N documented that Patient # 1 was transported by a family member to Hospital B at 6:16 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #1's psychiatric emergency, or contacted on call psychiatrist R, or made arrangements to admit Patient # 1 to any of 10 beds available on the 30 bed psychiatric unit located on 7 W (7th floor, West). Documentation provided by Research Medical Center during the EMTALA investigation revealed instead of going to Hospital B, the spouse took Patient # 1 home, and that later Patient # 1 was agitated and ran out into traffic and was killed. Refer to Tag A2407 for further details.

4. Review of a closed medical record revealed Patient #2 presented with law enforcement to the emergency department on 11/28/11 at 11:52 AM as a danger to self. The patient had been drinking alcohol for two to three days, without sleep, and hitting things to hurt himself. Documentation showed that Patient #2 was confused, disoriented, physically aggressive and combative to the point that security was contacted and the patient was restrained and later medically sedated. The transfer record, signed by the ED Physician, indicated that the patient was unstable and was to be transferred to Hospital B for inpatient psychiatric services. At 7:02 PM, the patient was transported by ambulance, with security, at 7:02 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #2's psychiatric emergency, or contacted on call psychiatrist T, or made arrangements to admit Patient #2 to any of 16 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details.

5. Review of a closed medical record revealed Patient # 4 presented to the ED on 12/09/11 at 3:14 PM, complaining of homicidal and suicidal ideations. Documentation on the Emergency Physician's Record indicated that the patient was depressed and having suicidal thoughts, planned to overdose, and had stopped taking psychiatric medications. Review of the transfer form showed documentation in the physician section indicating the transfer was medically indicated to obtain a service (psychiatric) that was unavailable at (Research Medical Center). The patient was transferred to Hospital B at 6:24 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #2's psychiatric emergency, or contacted on call psychiatrist S, or made arrangements to admit Patient # 4 to any of 22 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details.

6. Review of a closed medical record revealed Patient # 5 presented to the ED by ambulance on 11/26/11 at 12:03 AM, complaining of intoxication, depression, and wanting to die. At 12:06 AM, the ED physician examined the patient and documented the patient was depressed and having suicidal ideations, with a plan to overdose on her medication. At 2:45 AM, the patient was evaluated by a mental health professional who documented that the patient had a significant history of suicide attempts, poor impulse control and coping skills, and was a threat to herself. At 6:02 AM, the local fire department emergency service was contacted to transport the patient to Hospital B for inpatient psychiatric services and the patient was transferred at 7:20 AM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient # 5's psychiatric emergency, or contacted on call psychiatrist R, or made arrangements to admit Patient # 5 to any of 16 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details

7. Review of a closed medical record revealed Patient # 20 presented with law enforcement to the ED on 11/30/11 at 10:32 AM, after the patient was found yelling in the street and experiencing hallucinations. The ED nurse documented the patient was anxious, walking in the streets yelling and felt like terrorists had abducted him and were tearing his insides up, that he was continuously rambling and had a history of substance abuse. Documentation in the "Emergency Physician Record" indicated patient # 20 was agitated, hostile, experiencing auditory hallucinations, had prior thoughts of suicide, was schizophrenic and had not taken his anti-psychotic medication Zyprexa for two days. The medical record contained 16 handwritten pages in which patient # 20 expressed the belief that his body was occupied by terrorists and people close to him were being raped and abused. Documentation by Call Center staff U at 12:09 PM indicated arrangements were made to transfer Patient # 20 to Hospital B. Review of the transfer form revealed Physician Assistant V documented at 12:30 PM that patient # 20 required transfer to obtain a service (psychiatric) unavailable at (Research Medical Center). Review of the Physician Certification Statement specifying the reason for ambulance transportation to Hospital B revealed the "Pt (patient) is schizophrenic and is a flight risk." The medical record did not contain evidence that patient # 20 received treatment for his psychosis while in the ED, that his emergency medical condition was stable, that on call psychiatrist O had been contacted, or that arrangements were made to admit him to any of the 14 beds available on 7 W.

Based on record review and staff interview, an immediate jeopardy situation was found to exist when the hospital failed to provide stabilizing treatment within its capacity and capability to five (#1, 2, 4, 5, and 20) of 20 patients who presented to the hospital emergency department seeking care for an emergency psychiatric condition, out of a sample selected from November through December 2011.

Findings included:

1. Review of hospital policy titled, "Admission to 7W - Criteria and Process" dated 06/15/11, showed that capability of the inpatient psychiatric unit located on the 7th floor included patients who are/ or have:
-Age 18 to 65 years with psychiatric problems;
-Patients with suicidal ideation or attempt;
-Patients with physically aggressive threats or actions due to a treatable primary psychiatric condition;
-Patients with inability to care for self due to primary treatable psychiatric condition;
-Patients with significant impairment in social, familial, or occupational relations.

2. Review of the on call list revealed a psychiatrist was on call to the emergency department every day during the month of November and December when Patients # 1, 2, 4, 5 and 20 presented to the ED seeking care for a psychiatric emergency.

3. During an interview on 12/16/11 at 12:57 PM, the Nursing Director of the Intake Center located inside Hospital B stated that placement determination (patient admission ) is made by the call center staff and that they arrange admissions for all the Missouri hospitals in their corporate health system including Research Medical Center. The Director stated that patients aged 55 or older are transferred to Hospital B's senior unit and when questioned regarding the 18 - 65 age limit for the psychiatric unit on 7 West stated "probably the oldest patient they've had (referring to 7 W) was 58 years of age." When re-questioned regarding capability of the psychiatric unit on 7 West, the Director stated "anyone outside the age of 18 - 65, otherwise there is no one that cannot be managed on 7 West. "

4. Review of a closed medical record reported by Quality Risk Manager (QRM) B revealed Patient # 1 presented with family to the emergency department (ED) on 11/10/11 at 11:43 AM after threatening self harm. At 1:11 PM, ED nurse O documented that while in the radiology department for a CT scan (a special type of x-ray), Patient # 1 jumped off the table, ran down the hallway saying "staff want to kill me." ED nurse O documented she notified ED physician N "regarding the situation" Staff J, a Licensed Professional Counselor (LPC) examined Patient # 1 (time unknown) and documented at 4:02 PM that Patient # 1 appeared confused, obsessively checking own sense of reality, had difficulty distinguishing between what was real and what was a dream, cooperated with the exam on behalf of the spouse but then claimed the spouse was "not really my" spouse. Further documentation revealed Patient # 1's spouse found a letter saying "I'd kill myself, but I am too chicken" and that the patient had attempted suicide 20 years ago. Staff J documented arrangements to transfer Patient # 1 to Hospital B. Review of the transfer form revealed ED physician N documented at 3:45 PM that Patient # 1's transfer was medically indicated to obtain "Inpt (inpatient) psych (psychiatric) services unavailable (at Research Medical Center) and that transport would be provided by the local Fire Department emergency service. Review of the ED physician's progress note confirmed that Patient # 1 had been accepted by Hospital B but that the mode of transport changed and Patient # 1's spouse would provide the transportation. ED nurse N documented Patient # 1 left the ED with the spouse at 6:16 PM. The medical record did not contain evidence that Patient # 1's psychiatric emergency was stable in the ED, that on call psychiatrist R was contacted, or that arrangements were made to admit Patient # 1 to any of 10 beds available on the 30 bed psychiatric unit located on 7 W (7th floor, West). Documentation provided by Research Medical Center (RMC) during the EMTALA investigation revealed instead of going to Hospital B, the spouse took Patient # 1 home, and that Patient # 1 was agitated and ran out into traffic and was killed.

During an interview on 12/19/11 at 4:10 PM, LPC J stated that when she evaluated Patient #1 in the ED, the patient was anxious, confused, didn't recognize the spouse and was very depressed. "I really didn't trust the patient." "I felt the patient needed to be admitted." LPC J confirmed she did not attempt to arrange admission to the hospital's psych unit on 7 W because of Patient # 1's age (Patient # 1 met the age criteria for admission to 7 W). LPC J stated she requested admission to Hospital B's "Senior Unit" and the patient was accepted. LPC J stated she was informed later that night (by Hospital B), that the patient never showed up for admission. LPC J stated she found out the following day that Patient # 1 had died after jumping out of a car.

During an interview on 12/20/11 at 1:11 PM, ED Physician N stated he was concerned about Patient # 1's depression and felt the patient was a danger to self, but was unsure why the patient was admitted the Senior Unit at Hospital B. ED Physician N stated that patients admitted to Hospital B's Senior Unit usually have dementia, and Patient # 1 didn't have dementia.

During an interview on 12/19/11 at 11:00 AM, ED Physician G confirmed that he took over Patient # 1's care after ED Physician N went off duty. According to ED Physician G, LPC J reported to him that Patient # 1 was willing to be transported to Hospital B if the spouse could provide transportation. ED Physician G stated that when he changed the mode of transportation from ambulance to family (private vehicle), no one voiced any concerns. "I don't know how long it was after I changed the mode of transportation until the patient left." "I didn't discuss where the patient was going because the off going ED physician (physician N) said the mental health professional was making arrangements." "They determine where the patient will go, but I don't know how that whole process works, you would have to ask the mental health staff." ED Physician G confirmed that he did not see or evaluate Patient # 1.

During an interview on 12/16/11 at 12:57 PM, Staff D, Intake Director stated the call center staff consisted of Masters prepared Social Workers, Masters prepared Counselors, and Registered Nurses.

During an interview on 12/16/11 at 2:30 PM, Staff F, Call Center Staff member stated, "We (Call Center staff) do all placements for all patients (inpatient and outpatient) for all (Missouri Hospitals within our health system)." "We are required to find placement for every patient called into us (Call Center) who meet admission criteria."

5. Review of the closed medical record revealed Patient # 2 presented to RMC ED escorted by law enforcement on 11/28/11 at 11:52 AM. A report provided to the hospital by law enforcement indicated Patient # 2's family stated he suffered from schizoid effective disorder and psychosis, that he was not taking his medications, had been drinking alcohol, hadn't slept in 2 or 3 days, was not making sense and was having paranoid delusions. Two affidavits included in the medical record attested that the patient believed he was hearing secret coded messages in music, was injuring himself, and drinking excessively because he feared going to sleep. The ED nurse documented Patient # 2 was placed in four-point restraints (all 4 extremities restrained) after becoming physically aggressive, violent, combative, and destructive. While restrained, Patient # 2 continued to be agitated, clenching his fists and banging his head on the bed side rail while attempting to remove his restraints, later becoming confused and disoriented. At 2:36 PM, Patient # 2 became subdued and the ED nurse removed the restraints from the patient's left wrist and right ankle, and at 3:34 PM the remaining two restraints were removed. At 4:20 PM, an ED nurse documented that the patient began to pace, closed the room door, punched the door, and turned off the lights. Security was notified as well as the ED physician, who ordered the patient to be placed in four-point restraints and medicated with a sedative Benadryl (100 mg IM), an anti-anxiety Ativan (4 mg IM), and an anti-psychotic Haldol (10 mg IM). The transfer record, signed by the ED Physician, indicated that the patient was unstable and was to be transferred to Hospital B for inpatient psychiatric services. At 4:55 PM, Kansas City Fire Department (KCFD) was in the ED and assisted in moving Patient # 2 to a cot, and KCFD and RMC security escorted the patient to Hospital B by ambulance at 7:02 PM. The medical record did not contain evidence that Patient # 2's psychiatric emergency was stable in the ED, that on call psychiatrist T was contacted, or that arrangements were made to admit Patient # 2 to any of 16 beds available on the 30 bed psychiatric unit located on 7 W.

6. Review of a closed medical record revealed Patient # 4 presented to the ED on 12/09/11 at 3:14 PM, complaining of homicidal and suicidal ideations. ED nursing documentation at 4:09 PM, indicated that the patient had thoughts of suicide, thoughts of homicide, was experiencing auditory hallucinations, and had attempted suicide in the past. Review of the transfer form showed documentation in the physician section indicating the reason for the transfer was medically indicated to obtain a service (psychiatric) that was unavailable (at Research Medical Center). The patient was transferred to Hospital B at 6:24 PM. The medical record did not contain evidence that Patient # 4's psychiatric emergency was stable in the ED, that on call psychiatrist S was contacted, or that arrangements were made to admit Patient # 4 to any of 22 beds available on the 30 bed psychiatric unit located on 7 W.

During an interview on 12/19/11 at 1:00 PM, QRM B stated that based on medical record review and the call center log summary, the call center did not contact 7 W to determine capability and capacity for admitting Patient # 4.

During an interview on 12/19/11 at 2:05 PM, QRM B stated that after review of the 7 W inpatient census for 12/09/11, the facility had the capacity and capability to provide Patient # 4's inpatient psychiatric care.

7. Review of a closed medical record revealed Patient # 5 presented to the ED by ambulance on 11/26/11 at 12:03 AM, complaining of intoxication, depression, and wanting to die. At 12:06 AM, the ED physician examined the patient and documented the patient had a history of schizoaffective disorder, was depressed, having suicidal ideations, and planned to overdose on her medication. At 2:45 AM, the patient was evaluated by a mental health professional who documented that the patient had a significant history of suicide attempts, poor impulse control and coping skills, and was a threat to herself. At 6:02 AM, KCFD was contacted to transport the patient to Hospital B for inpatient psychiatric services and the patient was transferred at 7:20 AM. The medical record did not contain evidence that Patient # 5's psychiatric emergency was stable in the ED, that on call psychiatrist R was contacted, or that arrangements were made to admit Patient # 5 to any of 16 beds on the 30 bed psychiatric unit located on 7 W.

During an interview on 12/19/11 at 1:40 PM, QRM B stated that Patient # 5 was transferred to Hospital B because the patient had previously been admitted there.

During an interview on 12/19/11 at 2:05 PM, QRM B stated that after review of the 7 W inpatient census for 11/26/11, the facility had the capacity and capability to provide Patient # 5's inpatient psychiatric care.

8. Review of a closed medical record revealed Patient # 20 presented with law enforcement to the ED on 11/30/11 at 10:32 AM, after the patient was found yelling in the street and experiencing hallucinations. The ED nurse documented that patient # 20 was anxious, walking in the streets yelling and felt like terrorists had abducted him and were tearing his insides up, that he was continuously rambling and had a history of substance abuse. Documentation in the "Emergency Physician Record" indicated patient # 20 was agitated, hostile, experiencing auditory hallucinations, had prior thoughts of suicide, was schizophrenic and had not taken his anti-psychotic medication Zyprexa for two days. The medical record contained 16 handwritten pages in which patient # 20 expressed the belief that his body was occupied by terrorists and people close to him were being raped and abused. Documentation by Call Center staff U at 12:09 PM, indicated arrangements were made to transfer Patient # 20 to Hospital B. Review of the transfer form revealed Staff V documented at 12:30 PM that patient # 20 required transfer to obtain a service (psychiatric) unavailable at (Research Medical Center). Review of the Physician Certification Statement specifying the reason for ambulance transportation to Hospital B revealed the "Pt (patient) is schizophrenic and is a flight risk." The medical record did not contain evidence that patient # 20 received treatment for his psychosis while in the ED, that his emergency medical condition was stable, that on call psychiatrist O had been contacted, or that arrangements were made to admit him to any of the 14 beds available on 7 W.

9. During an interview on 12/19/11 at 10:32 AM, QRM B stated that based on staff interviews and record reviews during the EMTALA investigation, it was unclear how the hospital staff determined capacity and capability before transferring patients to another facility.