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Based on facility policies review, medical record reviews, observations, bed census reports, and providers, administrative and emergency department (ED) staff interviews, the facility failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the emergency department (ED) of 31 ED patients reviewed.

The findings include:

Patient #1 presented to the ED by private vehicle from the nursing home on 3/8/2022 at 2:12 PM with chief complaint of "...Psychiatric problem..." with onset of 1 week prior to presentation. Patient #1 presented with "...Bizarre behavior...Patient started making sexual advances to female nurses and patients. Tried to get into several female patients rooms. He exposed himself to several females and would not stop..." Patient #1 had a Certificate of Need (CON- legal document which is required by the court for an individual who is admitted to an inpatient behavioral health treatment resource without the consent of the individual receiving services) from the nursing home and was sent to the ED for evaluation. Patient #1 had been in the ED without being admitted to an in-patient facility for definitive care from 3/8/2022-4/27/2022 (51 days). Medical record review showed no documentation to indicate a daily psychiatric reassessment was performed by a physician. Patient #1's home medications (to include home psychiatric medications) were not ordered by a physician until 3/19/2022 (12 days after presenting to the ED). Medical record review of Patient #1's Medication Administration Record (MAR) showed Premarin (female hormone used to reduce physical and sexual aggression) had not been administered to the patient from 3/19/2022-4/26/2022 (39 days since ordered and 49 days since last dose on 3/8/2022). Patient #1 remained in the ED on 4/27/2022.

Refer to A-2407

Based on facility policies review, medical record reviews, observations, bed census reports, and providers, administrative and emergency department (ED) staff interviews, it was determined the facility failed to provide stabilizing treatment as required for 1 patient (Patient #1) of 31 sampled patients who presented to the emergency department with psychiatric problems, and never admitted to hospital but stayed in the ED for greater the 50 days.

The findings include:

Review of the facility's policy "EMTALA (Emergency Medical Transfer and Labor Act)" reviewed 8/2019 showed "...MSE: Medical Screening Exam...A physical and (mental when necessary) health evaluation used to determine if they have an emergency medical condition...EMC: Emergency Medical Condition...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual...in serious jeopardy...STABILIZATION: When a patient is deemed to have an emergency medical condition, the facility will provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility...If it is determined through a medical screening examination that an emergency medical condition exists...the emergency department personnel shall: Provide such further medical examination and treatment as may be required to stabilize the medical condition or provide treatment to the woman in labor, within the capabilities of the staff and facilities available at the hospital...or Transfer the individual to another facility..."

Review of the facility's policy "Medication Reconciliation" reviewed 1/2022 showed "...The medication reconciliation process is a team effort requiring the involvement of the patient and family, the physician, nurse, and pharmacist at [facility]...[facility] staff and medical staff will maintain and communicate accurate patient medication information..."

Review of the facility's policy "Boarding" reviewed 2/2022 showed "...Purpose: To assure safe, quality care for patients who are delayed leaving the emergency department...Patients who will remain in the emergency department greater than 8 hours after the disposition decision is made will be considered a boarded patient...Admission orders will be entered into CPSI [computer system] by the admitting provider and verified by nursing...The physician will reconcile home medications and order as appropriate. Medication administration will be documented on the CPSI MAR [medication administration record]..."

Review of the facility's policy "Psychiatric Patient Management" reviewed 3/2022 showed "...Purpose: To establish safe, effective plan of care of patients with psychiatric conditions...Patients who come to [facility] for care of a psychiatric condition or overdose will be placed in a safe environment. In the Emergency Department, rooms 6 and 7 will be used when available. On Med Surg, room 501 will be used. These rooms allow continuous observation, with one to one monitoring at a 360 degree viewing...Based on the results of tests ordered by the physician the patient will be medically cleared. When medical clearance is documented, the Crisis Response Team (CRT) will be notified...Patients will be given their home medications after a written order received from physician when [facility] does not carry their home medication or its equivalent...In the event there is a delay transferring the patient, the patient will receive ongoing care until placement is arranged. A delay of greater than 8 hours after the disposition decision time is considered boarding (see Boarding Policy)..."

Medical record review of a nursing home admission history and physical showed Patient #1 was admitted to a nursing home on 3/11/2021 after a lengthy hospitalization at an inpatient psychiatric facility due to "...psychotic & [and] combative..." behavior. Patient #1's admission diagnoses to the nursing home included Hypertension, Bipolar, Schizophrenia, Dementia, Difficulty with Ambulation, Iron Deficiency, Depression, and Osteoarthritis.

Medical record review of Resident Progress Notes showed Patient #1 was agitated and became aggressive toward the facility staff and touched a female resident inappropriately on 2/27/2022.

Medical record review of Resident Progress Notes showed Patient #1 had tried to enter female resident rooms on 3/8/2022.

Medical record review of Patient #1's medication list from the nursing home showed Premarin (female hormone used to reduce physical and sexual aggression) 0.3 milligrams (mg) by mouth once a day with start date of 3/4/2022. The medication was last administered on 3/8/2022 at 8:27 AM prior to going to the ED for evaluation.

Medical record review of a Certificate of Need (CON - legal document which is required by the court for an individual who is admitted to an inpatient behavioral health treatment resource without the consent of the individual receiving services) showed a psychiatric evaluation was performed for Patient #1 at the nursing home on 3/8/2022 at 11:57 AM by a Qualified Mental Health Provider and a CON was completed. The evaluation showed "...Pt. [Patient] has placed others in reasonable fear of violent behavior & serious physical harm to them due to his impulsivity & sexual inappropriate behaviors...Pt. needs treatment due to his impulsivity of possible harm to others...Pt. was given new medication w/o [without] success at this time..."

Medical record review of a mobile crisis consult report performed at the nursing home on 3/8/2022 at 12:45 PM showed "...Per staff reports from nursing home, ct. [client] has been preying on other female residents, closing himself in women's rooms, inappropriately touching female residents, and has exposed himself to staff..." Patient #1 had a history of combative behavior, impulse control disorder, and schizophrenia.

Medical record review of ED Nursing documentation showed Patient #1 presented to the facility's ED by private vehicle from the nursing home on 3/8/2022 at 2:12 PM with chief complaint of "...Psychiatric problem..." with onset of 1 week prior to presentation. Patient #1 presented with "...Bizarre behavior...Patient started making sexual advances to female nurses and patients. Tried to get into several female patients rooms. He exposed himself to several females and would not stop. Patient has CON from nursing home and was sent here for evaluation..." Patient #1 was triaged with an Emergency Severity Index (ESI) score of 4, indicating less urgent needs.

Medical record review of an ED Physician note showed Patient #1 had a MSE by a qualified medical provider on 3/8/2022 at 2:32 PM. The patient's past medical history included Schizophrenia. Further review showed "...PSYCHIATRIC...Agitation...Unable to control self..." Patient #1's physical exam showed the patient's affect was flat and quiet. Continued review showed diagnostic considerations for the patient's psychiatric problem included Bipolar Disorder, Conversion Disorder, and Schizophrenia.

Medical record review showed a CON was signed by an ED physician on 3/11/2022 at 4:59 PM. The CON showed "...Pt with multiple sexual outbursts in situation where lives. Hx [history] impulse disorder asserts to harm females sexually..." The necessity for involuntary treatment was documented as "...Pt with abusive plans towards women...needs treatment for impulsivity to harm others...No success with treatment at this time..." Continued review showed based on the physician's face-to-face examination of the patient, the physician concluded Patient #1 was subject to admission to a hospital or treatment resource.

Medical record review showed a second CON was signed by an ED physician on 3/16/2022 at 4:31 PM. The physician had consulted with the mental health crisis team in the area and "...determined that all available less drastic alternatives to placement in a hospital or treatment resource are unsuitable to meet the needs..." of Patient #1. The CON showed "...Has a history of bipolar disorder. Now presents with acute mania. Combative behavior. Inappropriate sexual advances. Active symptoms of psychiatric disorder. Patient has placed others in reasonable fear of violent behavior and serious physical harm to them due to his impulsivity and sexual inappropriate behaviors..." The necessity for involuntary treatment was documented as "...Has a history of bipolar disorder. Now presents with acute mania. Combative behavior. Inappropriate sexual advances...Active symptoms of psychiatric disorder. Patient has placed others in reasonable fear of violent behavior and serious physical harm to them due to his impulsivity and sexual inappropriate behaviors...Needs intensive inpatient psychiatric care. Needs treatment due to his impulsivity and possible harm to others...Patient started on new medications without success..." Further review showed based on the physician's face-to-face examination of the patient, the physician concluded Patient #1 was subject to admission to a hospital or treatment resource.

Medical record review of an ED Physician note dated 3/19/2022 at 2:15 PM showed Patient #1's CON had been rescinded and the ED physician spoke with a hospitalist regarding admitting the patient to the facility.

Medical record review of an ED Physician note dated 3/19/2022 at 2:15 PM showed "...WAS TOLD BY [Physician #2] THAT DON [Director of Nursing] DISALLOWED ADMISSION TO FLOOR..."

Medical record review of ED Physician notes from 3/8/2022-4/27/2022 showed no documentation a psychiatric reassessment/evaluation had been performed by a physician or midlevel provider for Patient #1 on 3/17/2022, 3/18/2022, 3/23/2022, 3/25/2022, 3/26/2022, 3/29/2022, 3/31/2022, 4/1/2022, 4/3/2022, 4/5/2022, 4/13/2022, 4/22/2022, and 4/23/2022.

Medical record review of a Medication Therapy Form (medication reconciliation and medication orders) showed the following home medications were ordered for Patient #1 by an ED physician on 3/19/2022 (12 days after presenting to the ED):
*Bupropion (antidepressant) 75 mg by mouth daily
*Donepezil (medicine for Dementia) 10 mg by mouth daily
*Iron (used to treat and prevent low iron) 325 mg by mouth twice daily
*Norvasc (medicine for high blood pressure) 2.5 mg by mouth daily
*Norvasc 5 mg by mouth daily
*Premarin 0.3 mg by mouth daily
*Sertraline (antidepressant) 100 mg PO daily

Medical record review of Patient #1's MAR showed Premarin 0.3 mg daily was listed to be administered at 9:00 PM. Continued review showed Premarin had not been administered to the patient from 3/19/2022-4/26/2022 (39 days since ordered at facility and 49 days since last dose).

Medical record review of physician orders from 3/8/2022-4/27/2022 showed no orders to admit Patient #1 to the facility (51 days).

The facility had 25 inpatient beds. Review of the facility's midnight census (including observation patients) from 3/8/2022-4/26/2022 showed the following:
*3/8/2022 census 7
*3/9/2022 census 7
*3/10/2022 census 10
*3/11/2022 census 13
*3/12/2022 census 13
*3/13/2022 census 17
*3/14/2022 census 21
*3/15/2022 census 18
*3/16/2022 census 15
*3/17/2022 census 16
*3/18/2022 census 19
*3/19/2022 census 13
*3/20/2022 census 14
*3/21/2022 census 16
*3/22/2022 census 14
*3/23/2022 census 14
*3/24/2022 census 12
*3/25/2022 census 15
*3/26/2022 census 8
*3/27/2022 census 12
*3/28/2022 census 13
*3/29/2022 census 14
*3/30/2022 census 14
*3/31/2022 census 13
*4/1/2022 census 11
*4/2/2022 census 12
*4/3/2022 census 16
*4/4/2022 census 19
*4/5/2022 census 20
*4/6/2022 census 18
*4/7/2022 census 14
*4/8/2022 census 13
*4/9/2022 census 9
*4/10/2022 census 14
*4/11/2022 census 11
*4/12/2022 census 12
*4/13/2022 census 16
*4/14/2022 census 14
*4/15/2022 census 13
*4/16/2022 census 14
*4/17/2022 census 12
*4/18/2022 census 12
*4/19/2022 census 12
*4/20/2022 census 18
*4/21/2022 census 14
*4/22/2022 census 20
*4/23/2022 census 13
*4/24/2022 census 14
*4/25/2022 census 19
*4/26/2022 census 18

Observations of the ED on 4/27/2022 from 8:50 AM-10:10 AM showed the ED census was 11 and Patient #1 remained in room #6. At 9:25 AM, Patient #1 was observed exiting the ED bathroom in a wheelchair. Patient #1 passed 3 female staff members and did not make inappropriate comments nor exhibit inappropriate sexual behaviors toward the female staff. The patient entered room #6 and closed the door behind him.

During an interview on 4/25/2022 at 3:00 PM, in the conference room, the Chief Nursing Officer (CNO) stated the possibility of moving Patient #1 to the medical floor had been discussed but there were concerns about taking him out of the familiar environment of the ED. The CNO stated a hospitalist had spoken with her about whether Patient #1 should be admitted to the hospital. Continued interview revealed she told the physician it was "...up to him..." as to whether he admitted the patient.

During review of Patient #1's Medication Therapy Form and interview on 4/27/2022 at 9:00 AM, in the ED, the CNO and the ED Nurse Manager confirmed Patient #1's home medications Bupropion 75 mg by mouth daily; Donepezil 10 mg by mouth daily; Iron 325 mg by mouth twice daily; Norvasc 2.5 mg by mouth daily; Norvasc 5 mg by mouth daily; Sertraline 100 mg by mouth daily; and Premarin 0.3 mg by mouth daily were not ordered until 3/19/2022 (12 days after presenting to the ED).

During review of Patient #1's MAR and interview on 4/27/2022 at 9:02 AM, in the ED, the CNO and the ED Nurse Manager confirmed Patient #1 had not received Premarin 0.3 mg by mouth daily while in the ED from 3/8/2022-4/26/2022 (50 days).

During an interview on 4/27/2022 at 9:05 AM, in the ED, Registered Nurse (RN) #1 confirmed Patient #1 remained in the ED and had not been admitted to the hospital. RN #1 stated he had asked about admitting Patient #1 to the facility but was told "...administration would take care of it..."

During an interview on 4/27/2022 at 9:45 AM, in the ED, Physician #1 stated Patient #1 had been exposing himself at the nursing home and had been brought to the ED for evaluation. Physician #1 stated "...overall he has been appropriate..." and stated a physician checked on the patient every shift. Physician #1 confirmed Patient #1 had not been admitted to the facility and remained in the ED. Physician #1 stated the "...Emergency Room is not the appropriate place to receive care long term..." Physician #1 state he was unaware as to why the patient had not been admitted "...possibly staffing because he requires direct visualization..."

During an interview on 4/27/2022 at 11:35 AM, in the conference room, the Pharmacy Director confirmed Premarin was not available in the pharmacy. Continued interview revealed the Pharmacy Director was not aware Premarin was needed for Patient #1 or he would have ordered the medication. Further interview revealed a paper MAR was used for Patient #1 because the patient had not been admitted to the facility. The Pharmacy Director stated paper MARs did not go to the pharmacy and were not "...actively..." reviewed by a pharmacist. "...I didn't know he needed [Premarin]...fell through the cracks..." The Pharmacy Director confirmed Patient #1 had not received Premarin from 3/8/2022-4/26/2022.

During an interview on 4/27/2022 at 11:42 AM, in the conference room, the ED Nurse Manager confirmed the ED physicians were expected to perform and document a daily psychiatric reassessment. The ED Nurse Manager confirmed there was no documentation to indicate a psychiatric reassessment had been completed for Patient #1 on 3/17/2022, 3/18/2022, 3/23/2022, 3/25/2022, 3/26/2022, 3/29/2022, 3/31/2022, 4/1/2022, 4/3/2022, 4/5/2022, 4/13/2022, 4/22/2022, and 4/23/2022.

Observation of the Special Care Unit on 4/27/2022 at 1:30 PM showed Room 501 (refer to Boarding policy) was located directly across from the nurse's station. There was a window with blinds which allowed direct visualization of the patient. The room had capability to be a safe room for psychiatric patients.

During a telephone interview on 4/27/2022 at 1:35 PM, Physician #2 confirmed an ED physician called and asked him about admitting Patient #1 to the hospital. Physician #2 stated there "...wasn't really medical criteria to admit to the floor..." Continued interview revealed Physician #2 "...didn't see a reason to admit to medical floor...didn't feel like he needed to be admitted..."

During a telephone interview on 4/28/2022 at 1:10 PM, RN #2 confirmed she did not notify the ED physician or ED Nurse Manager that Premarin was not available for Patient #1. Continued interview confirmed RN #2 did not request Premarin from the pharmacy and confirmed Patient #1 had not received Premarin while in the ED.

During a telephone interview on 4/28/2022 at 4:13 PM, Physician #3 stated he had spoken with a hospitalist about possibly admitting Patient #1 to the hospital. Physician #3 confirmed he was told the patient could not be admitted to the hospital. Physician #3 stated "...The ED is no place for a patient to be in limbo..." Continued interview revealed Physician #3 did not recall being told Premarin was not available for Patient #1.

During a telephone interview on 4/28/2022 at 4:20 PM, Licensed Practical Nurse (LPN) #1 confirmed Patient #1 had not received Premarin because it was not available. Continued interview revealed LPN #1 had not told a physician, the pharmacy, or the ED Nurse Manager the Premarin had not been available to administer to the patient.

During a telephone interview on 4/28/2022 at 4:30 PM, Physician #4 stated Patient #1 had not been admitted to the hospital because the patient didn't meet acute care hospital admitting diagnosis requirements. Physician #4 stated he had spoken with administration frequently about the patient. Continued interview revealed Physician #4 was not aware Premarin was not available to administer to the patient.

The facility failed to ensure that stabilizing treatment was provided within the capabilities of the staff and facilities available at the hospital while waiting for placement of patient #1 as evidenced by failing to ensure that their Boarding policy was followed. The facility failed to list Patient #1 as a boarded patient after being delayed in leaving the ED for greater that 8 hours on 3/8/22. A disposition decision was made on 3/8/2022 that Patient #1 required placement in a psychiatric facility. This system failure resulted in Patient #1 staying in the facility's ED for greater than 50 days. Additionally, the facility failed to ensure that their Policy titled "Psychiatric Patient Management" was followed by failing to admit Patient #1 to the hospital, as the facility had available beds from 3/8/ 2022 through 4/27/2022. The facility also failed to ensure that daily psychiatric reassessments was provide as initially planned; and failed to provide routine medications, to include the patient's home psychiatric medications in a timely manner for Patient #1.