HospitalInspections.org

Based on medical record review, incident report, staff interviews, and policies and procedures the allegation is substantiated.

Findings:

A review of facility's medical record revealed P#1 was seen in the emergency department (ED) on 3/4/24 at 2:58 p.m. for aggressive behavior.
Review of physical exam dated 3/4/24 at 3:57 p.m. revealed skin: findings: bruising present. No erythema or rash. Comments: scattered small bruises and abrasions, No large wounds or lacerations.
Review ED Course notes dated 3/4/24 at 18:56 revealed A PP covering psychiatric hold area was updated regarding plan for patient. He will follow up on urinalysis and urine drug screen. We are currently pending mental health evaluation to assist with crisis placement. Care coordination has also been consulted for assistance
Review of ED Provider Re-Evaluation note dated 3/5/24 at 17:36 revealed physical exam re-assessment patient 1013; pt has been medically cleared; awaiting inpatient placement.
Review of nursing note dated 3/4/24 at 18:15 revealed Pt arrives with binder of all medical treatment psychiatrist phone number. Parents provided staff with copies to help ease with ongoing care. Parents would like to be notified of care and hospital dispo (disposition).
Review of nursing note dated 3/5/24 at 21:39 revealed Nurse to nurse with Miles, RN at Ridgeview Smyrna with accepting provider Dr. Nkwocha. Transportation to be arranged after 1 AM per staff.
Review of nursing note dated 3/6/24 at 11:42 revealed PD (police department) called for ETA, per operator, they are dispatching an officer now.
Review of nursing note dated 3/6/24 at 19:25 revealed SO here to transfer to Rdgeview [sic] Smyrna ambulated out of department with officers and steady gait belongings was sent home with family.



A review of incident report #381445 dated 3/12/24 revealed follow up note details on 3/14/24 at 8:00 am with behavioral health service line medical director, ED Psychiatrist, DON with North Fulton ED, EDON with Cobb ED, Assistant Vice President of Behavioral Health Service Line, Compliance, Risk Management Coordination regarding concern. We discussed opportunities across the system to better serve this vulnerable patient population. We discussed designated sensory rooms and carts. Increased communication pathways. Strategies for cleanliness of patient care areas in the presence of extreme aggression and potential harm to staff. A decision was made for both the ES and BH (Behavioral Health) service lines to personally meet with P#1's mom and partner with her to better serve these patients and their families. Continued review revealed updated note details 3/14/24 11:04 am emails to P#1's mom asking if we could meet with her. After several email exchanges a meeting was set up for Friday 3/29/24 at 3:00 p.m.


An interview was conducted with Emergency Department Director (EDD) AA on 3/26/24 at 12:30 p.m. in the administration conference room. EDD AA stated that he was familiar with P#1 and his stay in the ED earlier this month. He continued to explain that during P#1 stay in the ED he remained agitated, combative and physically assaulting staff. He stated that due to his unpredictability he was transferred to the behavioral health facility by a Cobb County Sherrif. He continued to explain that Cobb County and Marietta city Sherrif officers will provide transportation for some patients if there is a safety issue. EDD AA stated that there should have been a conversation between the behavioral health liaisons with P#1's family prior to the transfer.


An interview was conducted with Behavioral Health Liaison (BHL) BB on 3/26/24 at 12:50 p.m. in the administration conference room. BHL BB stated that she did recall P#1 and is very familiar with his case from previous admissions to the hospital. She continued to explain that when she arrive to work the morning after P#1's admission in the ED (emergency department) she assumed from her experience that it would be difficult to find placement for P#1 due to his diagnosis of autism spectrum. She stated that she initially had a conversation with P#1's mom to determine what her wishes were for P#1 upon discharge. BHL stated that mom requested assistance in finding placement for P#1 because home would not be a safe discharge. She continued to explain that at the time of the conversation with P#1's mom P#1 had not been medically clear to be discharged yet and therefore she was working with MD EE to find other alternatives. BHL BB confirmed that she did speak with P#1's mom again during his stay in the ED. She confirmed that she did not speak with P#1's mom after P#1 was medically cleared and that she did not speak with P#1's mom once placement was secured.


A telephone interview was conducted with Registered Nurse (RN) CC on 3/26/24 at 5:10 p.m. RN CC stated that she did recall P#1 and providing care to him during his admission to the emergency department (ED). She continued to explain that she works the evening shift and each time she went to his room he was resting comfortably. RN CC stated that when patients are transferred to another facility the care coordination department will send out requests to all the nearest facilities and the first facility to accept the patient is where the patient will be transferred to. She continued to explain that if there is a patient who has violent tendencies it is not uncommon to contact the local Sherriff's office for transportation assistance. RN CC stated that the RN on duty at the time of P#1's discharge and/or behavioral health assessor would have been responsible for notifying P#1's family of his discharge and transfer to another facility.


A telephone interview was conducted with Registered Nurse (RN) DD on 3/27/24 at 8:15 a.m. RN DD stated that she did recall P#1 during his stay in the emergency department (ED). She continued to explain that she was not the RN on duty to care for P#1 however she was on duty when he was transferred by sheriff office to the mental health facility. RN DD stated that she handled the sheriff P#1's paperwork and personal items. She continued to explain that she did not meet P#1's family during his stay in the ED however, P#1's father called the ED a few days after his discharged looking for him and she spoke to his father and then his mother who were upset that they did not know he was transferred to another facility. RN DD stated that she did not call P#1's family prior to the transfer because he is over the age of 18 and to her knowledge there was no information in his chart regarding a medical power of attorney. She continued to explain that usually the Behavioral Health Assessor would contact the family to update them on their loved ones status.


A telephone interview was conducted with Medical Doctor (MD) EE on 3/27/24 at 9:00 a.m. MD EE stated that he did recall P#1 during his stay in the emergency department. He continued to explain that his only interaction with P#1's family was at admission. MD EE stated that he did follow up with speaking to P#1 outpatient psychiatrist who made the suggestion to change his medication. MD EE stated that a change was made to P#1 medication to stabilize the patient and adjustments were made to regulate his heart rate. He continued to explain that he did not expect P#1 to be accepted to any facility in the city because patients with his diagnosis and severe agitation generally do not get accepted to a mental health facility. MD EE continued to explain that when he left the facility for the day, he had ot been accepted anywhere and when he returned to work the next morning he was accepted to Ridgeview. He continued to explain that usually it is the responsibility of the RN to contact the patient's family regarding a change in condition and/or transfers for anyone with his diagnosis.


A review of the facility's "Disposition Planning" policy, Policy #CC-15-01, last revision January 2017, revealed purpose is to define a process to ensure continuity of high quality, cost effective patient care by facilitating appropriate patient and family participation in planning for a patient's health care needs. 1. Assessment: The physician will direct the Disposition Planning efforts, provide orders and approve plans for continuity of care. 2. Implementation: the health care team's on-going responsibility is to assess a patient's potential health care needs and to educate the patient/family in the management of the care required.


A review of the facility's "Patients' Rights and Responsibilities" policy, Policy #RI-01-01, last revision July 2016, revealed purpose to define a process to delineate the rights and responsibilities that a Patient has within the Wellstar Health System. 1. The patient has the right to access treatment and services. 2. The patient has the right to respect. 3. The patient has the right to effective communication. 3.4 to have diagnosis and treatment options explained including the need for transfer if necessary. 4. The patient has a right to be involved in care decision and to involve others.


A review of the facility's "Patient Transfer Into and Within Wellstar Hospitals and Outside of Wellstar" policy, Policy #CC-05-01, last reviewed October 2020, revealed Transfers outside of Wellstar. 2.4 Notify the Administrative Supervisor or unit charge nurse/director if a nurse or other qualified personnel needs to accompany the patient to the receiving facility. Supervisor or unit charge nurse/director will be notified, and arrangements will be made. 2.6 Ensure the patient, or their representative, consents to the transfer. Obtain written consent and document in the patient medical record.