HospitalInspections.org

Based on interview, record review, and according to the statutorily mandated Quality Improvement Organization (QIO) physician peer review conducted on 10/14/10 and 10/25/10, the facility failed to follow and enforce its policies to ensure compliance with the requirements of 489.24 for two patients (Patient #5 and Patient #14) out of 34 cases sampled from March - September 2010. The facility Emergency Department (ED) sees an average of 1095 patients per month.
Findings included:
Patient #5

Review of Patient #5's closed medical record dated 09/14/10, showed the patient presented to Northeast Regional Medical Center ED after law enforcement found the patient lost, confused, with unusual behavior (striking his/her head on the cage in the patrol car and uncontrollable laughing without reason), and a history of psychiatric disorders. The nursing assessment showed the patient presented with increasing periods of confusion and non-compliance with prescribed psychiatric medications for one month. According to documentation, the patient appeared nervous, with inappropriate behavior. The patient was evaluated medically, but did not receive a psychiatric evaluation by a mental health professional.

Review of policy #A-09-1036, titled "EMTALA-Medical Screening/Stabilization", dated 04/28/09 showed a emergency medical condition manifesting itself by acute symptoms, including psychiatric disturbances could reasonably result in placing the health of the individual in serious jeopardy (page 2, 1a).

Review of Policy #A-10-1037, titled "Involuntary 96 Hour Hold", date 06/20/10 showed (in part) patients that are determined to present a likelihood of serious harm to self or others as the result of a mental disorder may require involuntary detention and transfer to an appropriate facility (page 1). Likelihood of serious harm does not require actual physical injury to have occurred, and is defined in the policy as:
- a substantial risk that serious harm will be inflicted by a person upon his own person, as evidenced by recent threats, including verbal threats (page 1, #4a);
-a substantial risk that serious harm to a person will result because of an impairment in his capacity to make decisions with respect to his hospitalization and need for treatment (Page 1-2, #4b).

Review of Patient #5's closed medical record dated 09/14/10, showed the patient was discharged after receiving medication to treat a urinary tract infection and low potassium. The discharge instructions per the ED physician - 1) no smoking 2) follow-up with counseling center in the AM 3) Cipro 500 milligrams (an antibiotic) by mouth two times a day 4) not legible and 5) not legible. The patient was given and signed discharge instructions to follow up in three days for a urinary infection, and medication information for the prescribed drug Cipro (treatment for the UTI). There was no documented instruction given to the patient for follow-up with a counseling center in the morning.

Review of policy #A-09-1036 titled "EMTALA - Medical Screening/Stabilization", dated 04/28/09 showed stable for discharge is determined when a patient has reached the point where continued care could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care (page four).

The facility failed to follow policy for Patient #5, who presented to the facility ED after police witnessed confusion and inappropriate behavior, thus indicating the patient was a danger to him/herself. Written follow-up instructions for psychiatric care, per the physician, were not provided to the patient when the patient was discharged to him/herself.

Review of Patient #17's closed medical record dated 05/28/10 showed a local ambulance transferred the patient to Northeast Regional Medical Center after threatening self harm and self-injuring both hands. Nursing documentation showed the patient was homeless, had consumed alcohol, and wanted to jump off of a bridge and die. The patient's suicide lethality score was 47 (high is greater than 39), however, there was no documentation supporting continuous monitoring of the patient.
Review of policy #C-09-1041, titled "Care of the Suicidal Patient in Non-Psychiatric Facility", dated 11/01/09 showed high risk is defined as verbalizing clear intent for self harm with concrete and viable plan and requires the following (in part):
-continuous 1:1 direct observation, at arms length (page 2, Level 3, bullet #1);
-clinical status and patient safety will be documented every 15 minutes (page 2, Level 3, bullet #2).

Review of Patient #17's closed medical record dated 05/28/10 showed the ED physician examined the patient, documenting the patient had drank eight beers and planned to jump in the Mississippi River. The patient had a history of drug abuse, with a positive urine drug screen (marijuana and benzodiazepines). The ED Physician documented a clinical impression of "Suicidal Ideation".

Review of policy #A-09-1036, titled "EMTALA-Medical Screening/Stabilization", dated 04/28/09 showed a emergency medical condition manifesting itself by acute symptoms, including psychiatric disturbances and or symptoms of substance abuse could reasonably result in placing the health of the individual in serious jeopardy (page 2, 1a).

Review of Patient #17's closed medical record dated 05/28/10 showed Case Management was notified after the patient requested inpatient counseling and the nurse contacted a psychiatric hospital for Patient #17's transfer and admission. Documentation at 5:25 PM showed the patient left the room and was observed walking across the parking lot (indicating there was no 1:1 direct observation of the patient). There was no nursing documentation of attempts made to prevent the patient from leaving the hospital, discussing the risks of leaving, or the benefits of staying.

Review of policy #A-09-1036 showed the hospital may not establish, maintain, or enforce a policy that prohibits personnel from leaving the hospital to treat an individual in need of emergency services in the immediate vicinity of the hospital.

Review of Patient #17's closed medical record dated 05/28/10 showed the nurse notified the physician the patient had left at 5:50 PM, 25 minutes after the patient was observed leaving the hospital (per 5:25 PM documentation).

Review of policy #C-09-1041, titled "Care of the Suicidal Patient in Non-Psychiatric Facility", dated 11/01/09 showed if the patient requests or attempts to leave the hospital, the physician and case manager will be notified to assess the patient for 96 hour hold status.

During an interview on 09/21/10 at 11:35 AM, ED Medical Director stated if a patient does not have a 96 hour court order, we cannot keep the patient from leaving, even if they are suicidal.

Review of Policy #A-10-1037, titled "Involuntary 96 Hour Hold", date 06/20/10 showed (in part) patients that are determined to present a likelihood of serious harm to self or others as the result of alcohol abuse or a mental disorder may require involuntary detention and transfer to an appropriate facility (page 1). Likelihood of serious harm does not require actual physical injury to have occurred, and is defined in the policy as:
- a substantial risk that serious harm will be inflicted by a person upon his own person, as evidenced by recent threats, including verbal threats (page 1, #4a);
-a substantial risk that serious harm to a person will result because of an impairment in his capacity to make decisions with respect to his hospitalization and need for treatment (Page 1-2, #4b).

Review of Patient #17's closed medical record dated 05/28/10 showed the ED Physician documented the patient left against medical advice (AMA), indicating the facility was aware the patient was leaving the ED. There is no physician documentation of attempts made to prevent the patient from leaving, discussing the risks of leaving, or the benefits of staying.

Review of Policy #A-09-1040, titled "Patients Leaving Against Medical Advice", dated 08/01/09 showed whenever a patient wishes to discontinue medical services, the facility must have written documentation that the patient acknowledged that he/she is discontinuing medical services of his/her own insistence and against medical advice. Additionally, the supervisor or director must:
-hold a conference with the patient and family to discuss the patient's desire to leave services, the consequences of, and the alternatives to such action (page 1, #2, bullet 3);
-have the patient sign the Leaving Against Medical Advice Form (page 1, #2, bullet 3);
-explain and read the form to the patient and family (page 1, #2, bullet 4).

The facility failed to follow policy for Patient #17, who presented to the facility ED after inflicting self harm and threatening self harm. The patient did not receive continuous 1:1 monitoring for safety and eloped from the ED after the physician had clinically diagnosed the patient with Suicidal ideations (an Emergency Medical Condition). There was no initiation of a 96 hour hold process, no attempts were made to prevent the patient from leaving, discuss the risks associated with leaving, or the benefits of staying and receiving psychiatric care.

Based on interview and record review, and according to the statutorily mandated Quality Improvement Organization physician peer review conducted on 10/14/10, the hospital failed to provide an appropriate examination sufficient to determine whether an emergency medical condition existed for one patient (Patient #5) out of 34 cases sampled from March - September 2010. The Emergency Department (ED) sees an average of 1095 patients per month. There were no patients in the ED when the survey began.
Findings included:
Patient #5
Review of Patient #5's closed medical record dated 09/14/10 (first presentation), showed the patient was confused and did not know what he/she was doing or where he/she lived prior to arriving at Northeast Regional Medical Center's (NRMC) Emergency Department (ED). An affidavit completed by law enforcement showed local law enforcement was dispatched to a gas station, where the patient was handcuffed and placed in the patrol car for his/her safety. The patient began to hit his/her head on the cage of the vehicle and continued after being asked to stop. Patient #5 then began laughing, could not stop, and could not explain why.
During an interview on 09/21/10 at 3:00 PM, Officer #9 stated during his encounter with Patient #5, the patient was confused and did not know why he/she was at the gas station. The officer spoke with Patient #5 about going to Northeast Regional Medical Center (NRMC) Emergency Department (ED) for an evaluation after being asked to do so by local counseling center staff.
Further review of Patient #5's closed medical record dated 09/14/10 revealed law enforcement called an ambulance for transport of Patient #5 to the ED. Ambulance crew documented the patient had a previous psychiatric history and that law enforcement had contacted a local counseling center who advised the patient should be transported to the hospital ED for evaluation. The patient told the crew she was non-compliant with her medications (Prozac and Trazodone, used to treat depression), denied taking any illicit drugs, and did not want to hurt him/herself or anyone else.
Review of Patient #5's closed medical record dated 09/14/10 revealed at 9:28 PM, ED Registered Nurse #4 assessed the patient and documented the patient's behavior as inappropriate and nervous.
During an interview on 09/22/10 at 10:00 AM, RN #4 stated while patient #5 was in the ED on 09/14/10, the patient was "pretty close to (his/her) baseline".
Review of Patient #5's closed medical record date 09/14/10 showed RN #4 documented contacting a counselor at a local counseling center by phone at 9:45 PM. The counselor did not feel the patient was a threat to him/herself or others and did not need a psychiatric evaluation or hospitalization (the counselor did not come to the ED to examine the patient). The nurse documented the ED physician was notified of the counselor's decision.
Review of Pro-Med Care Complement record dated 09/14/10 at 9:45 PM revealed ED Physician #2 signed (indicating review) Patient #5's visit history, including a visit on 04/09/10 for depression with a diagnosis of suicidal ideations, which required transfer.
Review of closed medical record dated 09/14/10 revealed ED physician #2 examined Patient #5 at 9:45 PM and documented a 30 day gradual onset of the present illness. Physician #2 also documented the patient was a poor historian, anxious and depressed, and bipolar. Further review showed the patient was confused, had stopped psychiatric medications, but did not have thoughts of suicide. According to the physical exam completed by Physician #2, the patient was mildly/moderately anxious, disheveled, disoriented, and with a flat affect. The patient refused hospitalization or psychiatric care (indicating the physician had discussed hospitalization with the patient). Staff #2's documented Clinical impression: 1) report of mental confusion; 2) hypokalemia; 3) acute urinary tract infection (UTI); 4) Medically stable otherwise.

Review of closed medical record dated 09/14/10 at 10:00 PM revealed RN #4 collected a urine specimen which was positive for benzodiazepines (prescribed or street drug taken for sedation or to reduce anxiety) and showed 3+ bacteria, indicating a urinary tract infection. At 10:45 PM, the ED nurse collected a blood specimen which showed the patient's potassium (3.3) was low and pregnancy test was negative. At 11:45 PM, the ED nurse gave the patient 1 dose of Potassium Chloride 40 milliequivelence (to treat low potassium) and Levaquin 500 milligrams orally (to treat the UTI). At 11:51 PM, the ED nurse documented the patient was discharged. The discharge instructions per the ED physician - 1) no smoking 2) follow-up with counseling center in the AM 3) Cipro 500 milligrams (an antibiotic) by mouth two times a day 4) not legible and 5) not legible. The patient was given and signed discharge instructions to follow up in three days for a urinary infection, and medication information for the prescribed drug Cipro (treatment for the UTI).
Review of policy #A-09-1036 titled "EMTALA - Medical Screening/Stabilization", dated 04/28/09 showed stable for discharge is determined when a patient has reached the point where continued care could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care (page four).

Review of Patient #5's closed medical record dated 9/15/10 (second presentation) revealed the patient was returned to the ED at 7:14 PM by ambulance (with police) after stating he/she was going to kill him/herself and anybody who got in the way. Documentation showed the patient presented grossly unkempt and dirty with multiple scratches, marks, dirty hands and feet, and quite disheveled in appearance. At 7:15 PM, RN #5 documented the patient's overall suicide lethality score was 40 or greater (actual score was 97), indicating a high suicide risk. The nurse documented the patient was hearing voices and would harm him/herself "if I could".
During an interview on 09/22/10 at 6:35 AM, ED RN #5 stated 96 hours hold paperwork for a psychiatric evaluation and treatment was initiated by the ED nurse and physician (and later ordered by the judge) because the patient did not want to be hospitalized.
Review of Patient #5's closed medical record dated 09/15/10 revealed at 8:25 PM, RN #5 entered the patient's room to draw blood and the patient refused to cooperate. The nurse informed the patient 96 hour paperwork was in process and the patient continued to escalate and then left the ED.
During an interview on 09/21/10 at 11:35 AM, ED Medical Director stated if a patient does not have a 96 hour court order, we cannot keep the patient from leaving, even if they are suicidal.
During an interview on 09/21/10 at 3:50 PM, Police officer #10 stated when Patient #5 started leaving the ED, the ED physician told the staff to let the patient go, "the police can arrest (him/her) outside". Officer #10 stated the patient laid down in the middle of the street and made homicidal and suicidal threats, and began punching him/herself in the stomach. The patient was restrained by police and eventually brought back into the ED.
Review of Patient #5's closed medical record revealed RN #5 assessed the patient at 9:20 PM, after the patient was brought back into the ED. The patient was calm but continued to deny the need for psychiatric care. At 22:45 PM, the patient remained calm, but delusional and paranoid, and believed he/she was the Archangel. At 11:00 PM, blood and urine was obtained for testing. The urine drug screen was positive for Benzodiazepines and Opiates (street or prescribed drug used as a sedative). An IV was started on the patient, the patient was sedated, monitored throughout the remainder of the night, and transferred for psychiatric care the following day.

Based on interview and record review, and according to the statutorily mandated Quality Improvement Organization physician peer review conducted on 10/25/10, the hospital failed to provide stabilizing treatment for an emergency medical condition for one patient (Patient #17) out of 34 cases sampled from March - September 2010. The Emergency Department (ED) sees an average of 1095 patients per month. There were no patients in the ED when the survey began.
Review of Patient #17's closed medical record dated 05/28/10 showed a local ambulance transferred the patient to Northeast Regional Medical Center after injuring both hands and threatening self harm. Documentation of a nursing assessment at 3:10 PM, showed the patient was homeless, had consumed alcohol, and wanted to jump off of a bridge and die. The patient's appeared anxious and stated he/she "cannot take it any longer" and at times felt like harming him/herself. The patient's suicide lethality score was 47 (high is greater than 39), however, there was no documentation supporting continuous monitoring of the patient.
Further review of Patient #17's closed medical record dated 05/28/10 at 3:30 PM, showed the ED physician examined the patient, documenting the patient had drank eight beers and planned to jump in the Mississippi River. The patient had a history of drug abuse, with a positive urine drug screen (marijuana and benzodiazepines). The ED Physician documented a clinical impression of "Suicidal Ideation".

Review of Patient #17's closed medical record dated 05/28/10 showed the nurse collected lab specimens at 3:30 PM and 4:00 PM. At 4:05 PM, while completing an EKG (a test which looks at the electrical activity of the heart), the nurse documented she notified case management after the patient requested inpatient counseling. There is no assessment or evaluation documented by case management found in the patient's chart.

Review of Patient #17's closed medical record dated 05/28/10 showed the patient was assessed one time between 4:05 and 5:05 PM, at 4:30 PM, when patient was found to be cooperative. At 5:05 PM, the patient's plan of care was discussed with the patient's mother, which included transferring the patient to another facility for inpatient psychiatric therapy. At 5:20 PM, the nurse contacted a psychiatric hospital for Patient #17's transfer and admission. Further documentation by the nurse at 5:25 PM showed the patient left the room and was observed walking across the parking lot (indicating there was no 1:1 direct observation of the patient). There was no nursing documentation of attempts made to prevent the patient from leaving the hospital, discussing the risks of leaving, or the benefits of staying. Additionally, there is no documentation that case management was contacted to initiate a 96 hour hold on the patient.

Review of policy #C-09-1041, titled "Care of the Suicidal Patient in Non-Psychiatric Facility", dated 11/01/09 showed if the patient requests or attempts to leave the hospital, the physician and case manager will be notified to assess the patient for 96 hour hold status.

Review of Patient #17's closed medical record dated 05/28/10 showed at 5:50 PM, the nurse notified the physician that the patient had left, 25 minutes after the patient was observed leaving the hospital (per 5:25 PM documentation).

Review of Patient #17's closed medical record dated 05/28/10 showed the ED Physician documented the patient left against medical advice (AMA), indicating the facility was aware the patient was leaving the ED. There is no physician documentation of attempts made to prevent the patient from leaving, discussing the risks of leaving, or the benefits of staying.

During an interview on 09/21/10 at 11:35 AM, ED Medical Director stated if a patient does not have a 96 hour court order, we cannot keep the patient from leaving, even if they are suicidal.

The facility failed to provide stabilizing treatment for Patient #17, who presented to the facility ED with an emergency medical condition after inflicting self harm and threatening self harm. The patient did not receive continuous 1:1 monitoring for safety and eloped from the ED after the physician had clinically diagnosed the patient with Suicidal ideations. There was no initiation of a 96 hour hold process, no attempts were made to prevent the patient from leaving, discuss the risks associated with leaving, or the benefits of staying and receiving psychiatric care.