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Based on closed DED (Dedicated Emergency Department) medical record reviews, and physician and staff interviews, the hospital failed to provide an appropriate medical screening examination and necessary stabilizing treatment within the capability of the hospital's DED for 1 of 20 sampled patients (Patient #2) presenting to the hospital's DED.

The findings include:

1. Based on closed DED medical record reviews, and staff interviews, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 20 sampled patients (Patient #2).

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

2. The hospital failed to provide necessary stabilizing treatment for 1 of 20 sampled patients (Patient #2) presenting to the hospital's DED.

~cross refer to 489.24(d) (1-3), Stabilizing Treatment - Tag A2407.

Based on closed Dedicated Emergency Department (DED) medical record reviews, and staff interviews, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 20 sampled patients (Patient #2).

The findings included:

Review of the record for the 06/16/2017 Hospital A's DED visit at 1822, revealed the EMS transport record for Patient #2 indicated " ...female kneeling on grass, staring up at sun. Pt was CAO (calm, alert, oriented) x 4 ...LEO (Law Enforcement Officer) on scene stated that patient had been taken to 66 for x 3 days now ...Same stated that he had called mobile crisis, but it was going to take them three hours to get there to get her. LEO stated Pt needed transport to 66 (designation of Hospital A utilized by local law enforcement) to wait for mobile crisis ..." Patient #2's vital signs in Hospital A's DED recorded by RN (Registered Nurse) #14 on 06/16/2017 at 1858 were: BP 148/74, P 92, RR 20, oral temperature 98.0 F, and SpO2 99% on RA. Review revealed allergy status was verified at 1904. Review of a note by LCSW (Licensed Clinical Social Worker) #3 dated 06/16/2017 at 1900 stated "Patient (#2) does appear to be responding to internal stimuli ...telling God to come get her, and she is ready to die ... (MHC) planned to recommend IVC and inpatient psychiatric placement to (MD #9) however patient had eloped before then and went home." Review revealed no additional documentation for the encounter, and Patient #2 was removed from Hospital A's DED census on 06/16/2017 at 2300.

Interview on 02/01/2018 at 0930 with RN #14 revealed she could see that she had charted the vital signs in triage at 1858, but had no memory of the patient, or the circumstances of Patient #2's presentation or departure from the DED on the evening of 06/16/2017.

Interview on 01/31/2018 at 1220 with LCSW #3 revealed he had been informed of Patient #2's pending arrival in the DED on the evening of 06/16/2017, and based on his pre-arrival communications, had decided to recommend involuntary commitment to the physician. Interview revealed that because his office was not located within the DED, he did not know when the patient arrived, and LCSW #3 was unable to find Patient #2 when he arrived, and later entered a note in the record.

Based on closed DED (Dedicated Emergency Department) medical record reviews, and physician and staff interviews, the hospital failed to provide necessary stabilizing treatment for 1 of 20 sampled patients (Patient #2) presenting to the hospital's DED.

The findings included:

Closed medical record review for Patient #2 revealed a 80-year-old Caucasian female presented by Emergency Medical Services (EMS) transport on four successive days to Hospital A's DED on 06/14/2017 at 2359, 06/15/2017 at 1359, on 06/16/2017 at 1822, and 06/172017 at 1720.

Review of the record for the 06/14/2017 Hospital A's DED visit at 2359, revealed the EMS transport record for Patient #2 indicated EMS " ...arrived to find this 80 y/o female sitting outside in the rain. Neighbors stated she had been there all day sitting. PT (patient) states she is on watch for the Lord. Her last meal, because she states she is fasting, was prior day at dinner ..." Patient #2's vital signs in Hospital A's DED on 06/15/2017 at 0001 were: blood pressure (BP) 164/109, pulse (P) 138, respirations (RR) 18, oral temperature 98.5 (degrees) (Fahrenheit) F, and Pulse Oximetry (SpO2) 98% on room air (RA). Review of the initial Physician Assistant's (PA#1) note revealed Patient #2's pertinent medical and surgical history was bipolar disorder, and she had a "First degree sunburn to the top of head, forehead, and face" and a right eye infection. Orders entered and completed during the DED admission were cardiac and pulse oximetry monitoring, chest x-ray (CXR), a complete blood count (CBC), a complete metabolic panel (CMP), urine drug screen (UDS), urinalysis (U/A), serum ethanol (SE), and syphilis screen (RPR). Review revealed no significant test abnormalities were reported as a result of the visit. In review of an entry by PA #1, the patient was noted to be non-compliant with medications, and described as "calm," "cooperative," and a/o x 3 (alert and oriented to person, place and time). Review of an entry by a mental health contract agency (MHC) social worker (LCSW #3) dated 06/15 2017 at 0600 revealed Patient #2 had been admitted to an outside psychiatric facility in January of 2017, and had not continued taking her medications after discharge. Further review revealed " ...she refused outpatient referrals, and refused a crisis plan," and the DED physician (MD #4) had contacted the DED resource manager (RM #5) to engage Patient #2 and attempt to secure her cooperation in receiving at home assistance. Review revealed Patient #2 was discharged by PA #8 from the DED on 06/15/2017 at 1159. Review of a note by RM #5 from 06/15/2017 timed at 1205, and entered in the EMR at 1729 revealed RM #5 had spoken with LCSW #3 who indicated Patient #2 "does not meet criteria at this time" for inpatient psychiatric care, and a referral for home nursing and social work services had been agreed to by Patient #2 and completed, and because the patient did not have transportation home, special assistance with transportation home had been obtained from a local senior assistance transportation provider.

Review of the record for the 06/15/2017 Hospital A's DED visit at 1359, revealed the EMS transport record for Patient #2 indicated "Pt appeared to be experiencing hallucinations and was displaying psychotic behavior. Pts neighbor saw her outside talking to herself and was concerned for her health due to the heat." Patient #2's vital signs in Hospital A's DED on 06/15/2017 at 1420 were: BP 159/94, P 94, RR 18, oral temperature 98.8 F, and SpO2 94% on RA. Review of a note by PA # 6 signed on 06/06/2017 at 0053 revealed "Pt presents again today after discharge at 1100 with acute psychosis and 1st degree sunburn. She now presents because her neighbor caught her and helped her sit down when it appeared she was about to fall after standing and staring at the sun unresponsive for an unknown amount of time. She had also urinated on herself. Pt states she saw Jesus coming for her and then she didn't ...she is dehydrated ...the only treatment she needs during this presentation is rehydration ..." Continued review of the note indicated "Disposition: Admit to TU (Transitional Unit, a separate section of Hospital A's DED for patients with mental health concerns)." Continued review of the record revealed a note by LCSW #3 dated 06/15/2017 at 1500 which indicated Patient #2 had returned to the DED after returning home because she had lost her house key during the initial DED visit, was unable to re-enter her apartment, a neighbor had noticed Patient #2's worsening confusion and agitation after returning home, and had dialed 911. LCSW #3's note reiterated Patient #2 did not " ...meet criteria for inpatient psychiatric hospitalization." Review revealed Patient #2 was admitted, observation status, to the TU of the DED on 06/15/2017 at 2212. Orders entered and completed during the DED admission were cardiac and pulse oximetry monitoring, computed tomography (CT, an advanced x-ray imaging study) of the head, electrocardiogram (EKG, a study of the electrical activity of the heart), CBC, CMP, cardiac injury markers, coagulation studies, U/A, and UDS. Review revealed again, there were no significant test abnormalities reported for Patient #2's visit. Review of a note by PA #8 dated 06/16/2017 at 0855 revealed "States she did not sleep last night because she was up praying and 'watching'." Review of a note by MD #7 dated 06/16/2017 at 1459 stated "Patient (#2) is capable of making a rational decision. There is no indication or rationale for taking away her rights with involuntary commitment. Patient will be discharged per her request." Review of a note by RM #5 dated 06/16/2017 at 1612 indicated she had provided clothing to Patient #2 through a volunteer organization located in the facility, had arranged for transportation assistance services, and had completed home health services and adult protective services referrals which were to begin "as soon as possible." Review revealed Patient #2 was discharged by PA #6 from the TU of Hospital A on 06/16/2017 at 1601.

Review of the record for the 06/16/2017 Hospital A's DED visit at 1822, revealed the EMS transport record for Patient #2 indicated " ...female kneeling on grass, staring up at sun. Pt was CAO (calm, alert, oriented) x 4 ...LEO (Law Enforcement Officer) on scene stated that patient had been taken to 66 for x 3 days now ...Same stated that he had called mobile crisis, but it was going to take them three hours to get there to get her. LEO stated Pt needed transport to 66 (designation of Hospital A utilized by local law enforcement) to wait for mobile crisis ..." Patient #2's vital signs in Hospital A's DED recorded by RN #14 on 06/16/2017 at 1858 were: BP 148/74, P 92, RR 20, oral temperature 98.0 F, and SpO2 99% on RA. Review revealed allergy status was verified at 1904. Review of a note by LCSW #3 dated 06/16/2017 at 1900 stated "Patient (#2) does appear to be responding to internal stimuli ...telling God to come get her, and she is ready to die ...(MHC) planned to recommend IVC and inpatient psychiatric placement to (MD #9) however patient had eloped before then and went home." Review revealed no additional documentation for the encounter, and Patient #2 was removed from Hospital A's DED census on 06/16/2017 at 2300.

Review of the record for the 06/17/2017 Hospital A's DED visit at 1720, revealed the EMS transport record for Patient #2 indicated " ...female pt laying unconscious on the ground ...neighbor called ...pt was laying on her porch naked ...unconscious, breathing, non-responsive to pain ..." Patient #2's vital signs in Hospital A's DED on 06/17/2017 at 1752 were: BP 102/52, P 135, RR 27, temperature 102.2 F, and SpO2 98% on ventilator support with oxygen delivery set at three times above ambient air level. Orders entered and completed during the DED admission included cardiac and pulse oximetry monitoring, central and peripheral intravenous line insertion, intravenous sedation and antibiotic treatment, ventilator (breathing) support, enterogastric (stomach) tube insertion, computed tomography (CT, an advanced x-ray imaging study) of the head, CXR, EKG, CBC, CMP, serum ethanol level, cardiac injury markers, coagulation studies, U/A, and UDS. Review of a note dated 06/17/2017 at 1815 by the MHC staff, LCSW #10, revealed "Patient was found outside her house unconscious ...Patient was (sic) required intubation and central line and was medically transferred to (Named Hospital B)." Review of a note by in the DED record on 06/17/2107 timed at 2200 by MD #9 revealed "Pt is far too ill to be managed here." Review of the transfer record revealed Patient #2's vital signs in Hospital A's DED on 06/18/2017 at 0245 at the time of transfer to a tertiary care center intensive care unit were: BP 110/55, P 75, RR 20, temperature 96.3 F, and SpO2 100% on mechanical ventilator support.

Review of Patient #2's record at Hospital B revealed Patient #2 had been admitted to the medical intensive care unit (MICU) on 06/18/2017. Review of an admission history and physical signed by a resident physician on 06/18/2017 at 0543, and cosigned by an attending physician at 1315, revealed that Patient #2 arrived at Hospital B " ...intubated but appropriately following commands," and was able to be removed from mechanical ventilator support on 06/18/2017. Continued review revealed Patient #2 had fallen while an inpatient at Hospital B " ...after standing for a prolonged period in an attitude of worship (hands in the air)," and had been involuntarily committed, and discharged to a geriatric psychiatric facility on 07/06/2017.

Request for interview with MD #4 who was involved in care for Patient #2 during the first visit revealed he was not available for interview.

Request for interview with PA #8 who was involved in care for Patient #2 during the first visit revealed she was no longer at Hospital A.

Request for interview with PA #6 who was involved in care for Patient #2 during the second visit revealed she was no longer at Hospital A.

Interview on 02/01/2018 at 0915 with RN #15 revealed she remembered Patient #2, and had "picked her up at 0300" on 06/15/2017, and had "handed her over" to another nurse at the end of her shift at 0700. RN #15 remembered Patient #2's face was "very red" and she had put eye drops in one of Patient #2's eyes. During interview, RN #15 revealed Patient #2 "would talk about how Jesus was coming for her," but the patient had slept most of the time RN #15 had provided care.

Interview on 01/31/2018 at 1445 with RN #16 revealed, after review of the record, she had reported a mildly elevated lab result to the physician during the second visit for Patient #2 on 06/15/2017, and did not recall family being at the bedside, but remembered no other details of the visit.

Interview on 01/31/2018 at 1155 with RM #5, a social worker working as a resource manager in Hospital A's DED, confirmed she remembered Patient #2, and had worked to secure post discharge services for Patient #2's first two visits in June 2017. Interview revealed that RM #5 recalled that during the first visit, Patient #2 had a "Preoccupation with religion," and she had had concerns about Patient #2's decision making, but staff for MHC had evaluated Patient #2 and "said it was OK" for her to return home. Interview revealed that, at the time, the mental health services contractor, MHC, would make recommendations and the physician caring for the patient would either accept or make changes to the contractor's recommendations. During interview, RM #5 recalled that MD #4 had agreed to Patient #2's return home with a referral for home health services. Interview revealed RM #5 continued to be concerned about how soon home services could be delivered to Patient #2 after discharge from the TU during the second visit, but had been told the MHC and Physician #4 had reviewed Patient #2's condition, and had determined she could be discharged home.

Interview on 01/31/2018 at 1220 with LCSW #3 revealed that, prior to Hospital A's switch to tele-psychiatry services in the Fall of 2017, his MHC employer had provided mental health evaluations for providers in Hospital A's DED. Interview revealed LCSW #3 had been asked to evaluate Patient #2's mental status, and that as part of the evaluation, he had spoken with neighbors, and included assessment of her living situation. Interview revealed, initially, Patient #2 did not meet criteria as being an active threat of harm to herself or others despite her stay in an outside inpatient psychiatric unit in January of 2017, and medication non-compliance since her discharge from the facility. Interview revealed LCSW #3 had consulted a MHC supervisor for additional input on his recommendations, and it was believed that because Patient #2 had not met the screening criteria for self or other harm as a result of his interviews, she should be allowed to return home if that was her desire. Interview revealed that at Patient #2's second admission, she was again not considered to be a risk of harm to herself or others after a second screening exam, but overnight observation in the TU was coordinated. Interview with LCSW #3 revealed that Patient #2 had initially declined home services the first two visits, and refused to sign a "coping plan," but had eventually agreed to referral for home health services at the second visit. Interview with LCSW #3 revealed he had been informed of Patient #2's pending arrival in the DED on the evening of 06/16/2017, and based on his pre-arrival communications, had decided to recommend involuntary commitment to the physician. Interview revealed that because his office was not located within the DED, he did not know when the patient arrived, and LCSW #3 was unable to find Patient #2 when he arrived, and later entered a note in the record.
Interview on 02/01/2018 at 0930 with RN #14 revealed she had been a nurse in Hospital A's DED for 16 years, and could see that she had charted the vital signs in triage at 1858, but had no memory of the patient, or the circumstances of Patient #2's presentation or departure from the DED on the evening of 06/16/2017.

Interview on 01/31/2018 at 1115 with RN #11 confirmed she had assisted in the care of Patient #2 during the late evening of 06/17/2017 and early morning hours of 06/18/2017 when Patient #2 was being stabilized and prepared for transfer to an inpatient intensive care unit (ICU) at Hospital B. Interview revealed RN #11 had "reported off to (a nurse at) Hospital B," and Patient #2's vital signs were stable at the time of transfer. During interview, RN #11 recalled that Patient #2 had been hyper-thermic, and unresponsive at arrival, and had required mechanical ventilation support. Interview revealed RN #11 did not remember why Patient #2 had come to Hospital A's DED.

Interview on 02/01/2018 at 0700 with MD #14 revealed that he had been the original supervising physician for PA #6 for Patient #2's second visit TU observation stay, and ensuing discharge on 06/16/2017, but had not seen the patient. MD #14 indicated the note had been cosigned by MD #4 after MD #14's shift had ended at 1500, and he had departed the DED. During the interview, MD #14 revealed he had worked with staff of the MHC, had found their input useful, their recommendations were "generally pretty conservative," and "thought they did a good job."

The SA recommends non-compliance with 42 CFR 489.20 and 42 CFR 489.24. The SA requests a QIO review for Patient #2. The findings of the investigation were forwarded to the CMS Regional office (Region IV) in Atlanta, Georgia for final determination of compliance.

NC00135400