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Based on document review and staff interviews, the acute care hospital (ACH) staff failed to ensure the medical staff followed hospital policies and ensured 1 of 9 patients selected for review, that presented with suicidal thoughts (Patient #3) and 2 of 2 sampled patients who presented with broken bones in an extremity (Patient #17 and Patient #21) received all available stabilizing treatment including inpatient admission to the hospital or surgical repair of broken bones. Failure to provide all appropriate stabilizing treatment, including admission to the hospital resulted in the hospital staff transferring Patient #3 to another hospital located approximately 70 miles away from Mary Greeley Medical Center (MGMC) when the hospital had beds available for the staff to admit Patient #3. Failure to provide all available stabilizing treatment, including surgical repair of broken bones, resulted in hospital staff transferring 2 patients to a hospital (Hospital C) located approximately 35 miles away from MGMC when the on-call orthopedic surgeon had privileges to perform the surgery at MGMC. The hospital's administrative staff identified an average of 2375 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings inlcude:

1. Review of the hospital policy "Transfer Policy," revised 1/2017, revealed in part, "... Mary Greeley [Medical Center staff] will stabilize and treat the emergency condition or transfer the individual appropriately..." The policy lacked information regarding the admission of patients with unstabilized emergency medical conditions or requirement for the hospital to provide all stabilizing treatment within the hospital's capabilities and capacity.

2. Review of Patient #3's medical record revealed they presented to MGMC's dedicated emergency department on 12/19/18 at 1:45 PM, after taking an intentional overdose of Trazadone (a sedative and anti-depressant). ARNP A documented Patient #3 was calm and cooperative, sleepy, easily redirected from paranoid thoughts, and tried to commit suicide with the overdose of Trazadone.

Crisis Nurse B (a nurse with specialized experience in treating patients with behavioral health problems in the ED) documented she spoke with Psychiatrist C (a physician with specialized training in treating patients with behavioral health problems). Psychiatrist C felt Patient #3 required admission to the hospital on a medical floor prior to admitting Patient #3 to a high acuity behavioral health bed (an inpatient mental health bed where the staff closely monitor patients with video cameras due to the patient's history of violence, aggression, or high risk of hurting themselves or others).

Crisis Nurse B documented ED Physician D evaluated Patient #3 and cleared the hospital staff to admit Patient #3 to an inpatient mental health bed. Crisis Nurse B documented MGMC lacked an available inpatient high acuity bed, so she began looking to see if other hospitals had an available inpatient mental health bed for Patient #3. Crisis Nurse B found an available bed at Hospital B, and arranged to transfer Patient #3 via secure car (a private vehicle, similar to a sheriff's deputy's car, where the rear seat passenger can not open the rear doors from the inside). The hospital staff transferred Patient #3 to Hospital B at 9:58 PM on 12/19/18.

3. During an interview on 12/26/18 at 1:00 PM, Psychiatrist C C felt Patient #3 required a high acuity bed because Patient #3 did not feel safe anywhere, would not agree to tell hospital staff if they had thoughts of hurting themselves, and was hearing voices telling Patient #3 to overdose on medication. Psychiatrist C felt the ED staff should admit Patient #3 to a telemetry floor and stabilize Patient #3's low potassium, low Depakote level, and monitor Patient #3 for side effects of the Trazadone overdose.

4. During an interview on 12/26/18 at 8:00 AM, ED Physician E (a physician with specialized training in treating emergency medical conditions) disagreed with Psychiatrist C that Patient #3 required admission to a telemetry floor for stabilization prior to admission to the inpatient behavioral health unit. ED Physician E described Patient #3's behavior as calm, sleepy, and Patient #3 did not cause any problems for the ED staff.

5. Review of Patient #17's medical record revealed Patient #17 presented to the hospital's emergency department on 10/10/18 at 5:27 PM via ambulance. Patient #17 was involved in a motor vehicle accident and was complaining of pain in their right arm. ED Physician F examined Patient #17 and ordered an x-ray of their right arm. The x-ray revealed a fracture in 1 of the 2 bones in Patient #17's right forearm. The x-ray revealed that Patient #17 had dislocated the other bone in their right forearm. ED Physician F contacted on-call Orthopedic Surgeon G (a physician with specialized training in the surgical repair of broken bones) to examine Patient #17. Orthopedic Surgeon G evaluated Patient #17 and determined Patient #17 required transfer to Hospital C, for an orthopedic trauma surgeon. Orthopedic Surgeon G arranged for the hospital's ambulance service to transfer Patient #17 to Hospital C. The hospital staff transferred Patient #17 to Hospital C at 6:58 PM on 10/10/18.

6. During an interview on 12/26/18 at 1:00 PM, Orthopedic Surgeon G acknowledged his surgical privileges allowed him to repair all broken bones in the body, including broken bones in the forearm such as Patient #17's fractures.

7. Review of Patient #21's medical record revealed Patient #21 presented to the hospital's emergency department on 9/3/18 at 1:13 AM via ambulance. Patient #21 was involved in a motor vehicle accident and was complaining of pain in their right lower leg. ED Physician H examined Patient #21 and ordered an x-ray of Patient #21's right leg. The x-ray showed fractures in both of the bones in Patient #21's lower leg. ED Physician H contacted on-call Orthopedic Surgeon I. Orthopedic Surgeon I instructed ED Physician H to place a cast on Patient #21's right leg and transfer Patient #21 to Hospital C for another orthopedic surgeon to repair Patient #21's broken bones. ED Physician H arranged for the hospital staff to transfer Patient #21 to Hospital C. The hospital staff transferred Patient #21 to Hospital C on 9/3/18 at 4:08 AM.

8. During an interview on 12/24/18 at 10:00 AM, Orthopedic Surgeon I acknowledged his surgical privileges allowed him to repair all broken bones in the body, including broken bones in the lower leg such as Patient #21's fractures.

Please see A-2407 for additional information.

I. Based on document review and staff interviews, the acute care hospital (ACH) staff failed to ensure 1 of 9 patients selected for review, that presented with suicidal thoughts (Patient #3), received all appropriate stabilizing treatment, including admission to the hospital. Failure to provide all appropriate stabilizing treatment, including admission to the hospital resulted in the hospital staff transferring Patient #3 to another hospital located approximately 70 miles away from Mary Greeley Medical Center (MGMC) when the hospital had beds available for the staff to admit Patient #3. The hospital's administrative staff identified an average of 2375 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #3's medical record revealed they presented to MGMC's dedicated emergency department on 12/19/18 at 1:45 PM, after taking an intentional overdose of Trazadone (a sedative and anti-depressant). Patient #3 admitted to taking an overdose of approximately 700 mg of Trazadone (maximum usual dosage: 400 mg/day) approximately 1 hour prior to arriving at MGMC's emergency department (ED). Patient #3 had not taken their Depakote (a medication to control seizures) for 3 days. Advanced Registered Nurse Practitioner (ARNP) A documented that Poison Control (experts at managing patients who took medication overdoses) recommended to check Patient #3's Depakote level, perform an EKG (a tracing of the heart's electrical rhythm), and observe Patient #3 for 4-6 hours in the ED. ARNP A documented Patient #3 was calm and cooperative, sleepy, easily redirected from paranoid thoughts, and tried to commit suicide with the overdose of Trazadone. ARNP A documented Patient #3's laboratory testing revealed Patient #3's potassium was slightly low and Patient #3's Depakote level was low. Patient #3's EKG showed Patient #3's QRS complex duration (part of the heart rhythm showing the time electricity takes to travel through the heart) was 139 milliseconds (normal is less than 120 ms). ARNP A documented Patient #3 required inpatient mental health care.

Crisis Nurse B (a nurse with specialized experience in treating patients with behavioral health problems in the ED) documented she spoke with Psychiatrist C (a physician with specialized training in treating patients with behavioral health problems). Psychiatrist C felt Patient #3 required admission to the hospital on a medical floor prior to admitting Patient #3 to a high acuity behavioral health bed (an inpatient mental health bed where the staff closely monitor patients with video cameras due to the patient's history of violence, aggression, or high risk of hurting themselves or others).

Crisis Nurse B documented ED Physician D evaluated Patient #3 and cleared the hospital staff to admit Patient #3 to an inpatient mental health bed. Crisis Nurse B documented MGMC lacked an available inpatient high acuity bed, so she began looking to see if other hospitals had an available inpatient mental health bed for Patient #3. Crisis Nurse B found an available bed at Hospital B, and arranged to transfer Patient #3 via secure car (a private vehicle, similar to a sheriff's deputy's car, where the rear seat passenger can not open the rear doors from the inside). The hospital staff transferred Patient #3 to Hospital B at 9:58 PM on 12/19/18.

2. Review of the document "Hourly Census - Inpatient 12.18.18 to 12.20.18," revealed the hospital had between 5 to 7 inpatient behavioral health beds available for patients during Patient #3's stay in MGMC's ED. Review of the document revealed the hospital had 7 inpatient ICU (intensive care unit) beds available for patients during Patient #3's stay in MGMC's ED. Review of the document revealed the hospital had between 4 to 10 inpatient telemetry (where hospital staff can remotely monitor a patient's heart rhythm) beds available for patients during Patient #3's stay in MGMC's ED.

3. During an interview on 12/26/18 at 9:00 AM, Registered Nurse (RN) D stated she took care of Patient #3 in the ED. She called Poison Control. The Poison Control staff suggested the MGMC ED staff monitor Patient #3 for 4 to 6 hours in the ED, perform laboratory testing, and monitor Patient #3's EKG for an increase in his QRS duration. If Patient #3's QRS duration increased above 120 ms, the hospital staff should administer sodium bicarbonate (a medication to raise the pH of Patient #3's blood) via intravenous (IV) infusion. Patient #3 was cooperative with her, and was not combative or aggressive. RN D felt Patient #3 did not meet the criteria for an inpatient high acuity mental health bed.

4. During an interview on 12/26/18 at 1:00 PM, Psychiatrist C stated she admitted patients to high acuity inpatient mental health beds if the patient had acute psychosis or was highly agitated. Psychiatrist C felt Patient #3 required a high acuity bed because Patient #3 did not feel safe anywhere, would not agree to tell hospital staff if they had thoughts of hurting themselves, and was hearing voices telling Patient #3 to overdose on medication. Psychiatrist C felt the ED staff should admit Patient #3 to a telemetry floor and stabilize Patient #3's low potassium, low Depakote level, and monitor Patient #3 for side effects of the Trazadone overdose.

5. During an interview on 12/26/18 at 8:00 AM, ED Physician E (a physician with specialized training in treating emergency medical conditions) stated he examined Patient #3. When the nursing staff contacted Poison Control, the Poison Control staff informed the nursing staff to monitor Patient #3 for 4 to 6 hours. ED Physician E disagreed with Psychiatrist C that Patient #3 required admission to a telemetry floor for stabilization prior to admission to the inpatient behavioral health unit. ED Physician E was not concerned about the delay in Patient #3's QRS duration and did not feel that Patient #3 required inpatient telemetry monitoring for the increased QRS duration. ED Physician E described Patient #3's behavior as calm, sleepy, and Patient #3 did not cause any problems for the ED staff.

6. During an interview on 12/26/18 at 9:30 AM, Crisis Nurse B revealed the hospital had 4 beds out of the 11 inpatient behavioral health beds designated as high acuity inpatient mental health beds. The psychiatrists admitted patients who currently heard voices and actively tried to hurt themselves or others. Crisis Nurse B stated that Psychiatrist C determined if Patient #3 required a high acuity inpatient mental health bed or not, but Crisis Nurse B felt that Patient #3 required an high acuity inpatient mental health bed because the inpatient mental health unit staff had not cared for Patient #3 previously. Crisis Nurse B stated she arranged for Patient #3 to transfer to Hospital B via secure car. Crisis Nurse B transferred all behavioral health patients to other facilities by secure car, because secure car was the only method to transfer behavioral health patients. MGMC had a contract with a private company to transport behavioral health patients via secure car, and the hospital's ambulance service did not transport behavioral health patients to other hospitals.



II. Based on document review and staff interview, the hospital's administrative staff failed to ensure 2 of 2 sampled patients who presented with broken bones in an extremity (Patient #17 and Patient #21) received all available stabilizing treatment, including surgical repair of the broken bones, at the hospital. Failure to provide all available stabilizing treatment, including surgical repair of broken bones, resulted in hospital staff transferring 2 patients to a hospital (Hospital C) located approximately 35 miles away from MGMC when the on-call orthopedic surgeon had privileges to perform the surgery at MGMC. The hospital's administrative staff identified an average of 2375 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #17's medical record revealed Patient #17 presented to the hospital's emergency department on 10/10/18 at 5:27 PM via ambulance. Patient #17 was involved in a motor vehicle accident and was complaining of pain in their right arm. ED Physician F examined Patient #17 and ordered an x-ray of their right arm. The x-ray revealed a fracture in 1 of the 2 bones in Patient #17's right forearm. The x-ray revealed that Patient #17 had dislocated the other bone in their right forearm. ED Physician F contacted on-call Orthopedic Surgeon G (a physician with specialized training in the surgical repair of broken bones) to examine Patient #17. Orthopedic Surgeon G evaluated Patient #17 and determined Patient #17 required transfer to Hospital C, for an orthopedic trauma surgeon. Orthopedic Surgeon G arranged for the hospital's ambulance service to transfer Patient #17to Hospital C. The hospital staff transferred Patient #17 to Hospital C at 6:58 PM on 10/10/18.

2. Review of the hospital's website revealed the hospital's capabilities included an intensive care unit and dedicated emergency department designated by the State as a Level III trauma center (the hospital is capable of treating almost every injury or illness on site).

3. Review of the "October 10, 2018 On Call Schedule" revealed Orthopedic Surgeon G's name listed as on-call for orthopedic surgery.

4. Review of Orthopedic Surgeon G's surgical privileges (a list of surgical procedures the hospital's medical staff and governing body gave permission for Orthopedic Surgeon G to perform at the hospital), approved by the medical staff on 7/21/17 and approved by the governing body on 7/24/17, revealed Orthopedic Surgeon G could perform surgery for "fracture fixation" and "open reduction and internal ... fixation of fractures and dislocations" (surgical repair of broken bones, including using screws, plates, and rods to hold the broken bone together until the body healed the fracture).

5. During an interview on 12/26/18 at 1:00 PM, Orthopedic Surgeon G acknowledged his surgical privileges allowed him to repair all broken bones in the body, including broken bones in the forearm such as Patient #17's fractures. .

6. Review of Patient #21's medical record revealed Patient #21 presented to the hospital's emergency department on 9/3/18 at 1:13 AM via ambulance. Patient #21 was involved in a motor vehicle accident and was complaining of pain in their right lower leg. ED Physician H examined Patient #21 and ordered an x-ray of Patient #21's right leg. The x-ray showed fractures in both of the bones in Patient #21's lower leg. ED Physician H contacted on-call Orthopedic Surgeon I. Orthopedic Surgeon I did not present to the ED, but instead instructed ED Physician H via phone to place a cast on Patient #21's right leg and transfer Patient #21 to Hospital C for another orthopedic surgeon to repair Patient #21's broken bones. ED Physician H arranged for the hospital staff to transfer Patient #21 to Hospital C. The hospital staff transferred Patient #21 to Hospital C on 9/3/18 at 4:08 AM.

7. Review of the "September 3, 2018 On Call Schedule" revealed Orthopedic Surgeon I's name listed as on-call for orthopedic surgery.

8. Review of Orthopedic Surgeon I's surgical privileges (a list of surgical procedures the hospital's medical staff and governing body gave permission for Orthopedic Surgeon I to perform at the hospital), approved by the medical staff on 7/20/18 and approved by the governing body on 7/23/18, revealed Orthopedic Surgeon I could perform surgery for "fracture fixation" and "open reduction and internal ... fixation of fractures and dislocations" (surgical repair of broken bones, including using screws, plates, and rods to hold the broken bone together until the body healed the fracture).

9. During an interview on 12/24/18 at 10:00 AM, Orthopedic Surgeon I acknowledged his surgical privileges allowed him to repair all broken bones in the body, including broken bones in the lower leg such as Patient #21's fractures.