HospitalInspections.org

Based on facility document review and staff interviews, the facility staff failed to ensure necessary stabilizing treatment was provided to one (1) of twenty (20) patients included in the survey sample, Patient #2 (Pt #2) prior to the law enforcement officer (LEO) transferring the patient to a facility named in a temporary detention order (TDO).

Based on Pt #2's medical record review, Pt #2 presented to facility initially voluntary and then after elopement under emergency custody order (ECO) due to potential for self harm. Pt #2 was to be assessed every 4 hours using Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and have vitals monitored. The last reassessment documented on 8/5/23 at 7:50 am identified a substantial change in condition. The medical record failed to contain evidence that the provider was notified of the change in condition and the provider did not reassess the patient prior to being removed from the facility by LEO at 11:07 am.

The facility was found out of compliance with the EMTALA requirements at 42 CFR §489 (Rev. 7-19-19) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Please refer to tag A-2407 for details.

Based on medical record and document review, the facility failed to ensure stabilizing treatment was provided for Patient #2 (Pt #2), one (1) of twenty (20) emergency department (ED) patients included in the survey sample.

The findings included:

Pt #2's medical record evidenced that the patient was ordered a CIWA (alcohol withdrawal) assessment due to their history and their alcohol serum level of 167.80 (normal range less than 3.0) on 8/4/23 at 9:51 p.m. The medical record contained evidence of a CIWA assessment started on 8/5/23 at 2:57 a.m. and vital signs were taken at 3:13 a.m. which were within normal limits. The CIWA score at that time was 6 (six).
Pt #2's second CIWA assessment was started on 8/5/23 at 7:50 a.m. and documented CIWA score of 14 but no vital signs were documented. The medical record didn't contain evidence of existing medication order for alcohol withdrawal and that the provider was notified of the change in condition. The medical record evidenced that at the time of Pt #2 removal from the Emergency Department by Law Enforcement Officer (LEO), the ED staff were actively trying to obtain acceptance of Pt #2 to this facility's psychiatric unit. Pt #2's medical record documented in "Departure Information" section in part, "... Disposition: Against Medical Advice Departure Date/Time: 08/05/23 - 1001 Condition: Stable..."

A facility policy, Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) Policy, last revised 08/2020, evidenced, in part, "...Policy...1. CIWA-Ar assessments will be completed on admission and minimum of every 4 hours for patients scoring > 4 on Scale (PAWSS). 3. Obtain complete set of vital signs in conjunction with each CIWA-Ar assessment ... Procedure ... 8-15 (Moderate) Medication is indicated to reduce symptoms and the risk of major complications. Contact physician if patient's treatment plan does not include medication orders for alcohol withdrawal..."

After reviewing the CIWA-Ar policy, it was determined that the facility staff failed to perform the second CIWA assessment within the "minimum of every 4 hours", failed to obtain vital signs with the second assessment and contact physician about medication order for alcohol withdrawal.