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Based on interview and record review, the facility failed to follow and enforce policies to ensure compliance with the requirements of 489.24 for three patients (Patient #2, #6, and #12) out of 4 cases sampled from February 14 - 23, 2011. The facility Emergency Department (ED) sees an average of 1021 patients per month.
Findings included:

Patient #2
Review of Patient #2's closed medical record dated 02/14/11, showed the patient presented to Northeast Regional Medical Center's ED requesting admission to help stop drinking at 7:18 AM. The patient had a 10 year history of drinking a six pack of beer and a fifth or vodka or whiskey daily, and reported he/she had a seizure (the patient had no history of seizures) after he/she tried to quit drinking the day before. The patient added that he/she became so agitated the following morning (morning of arrival to the ED), that he/she drank a beer and took ativan (sedative) to calm down. The ED physician examined the patient but the medical record does not contain any documentation whether the patient was at risk of having another seizure after discharge when withdrawing from alcohol. The ED nurse documented the patient's hand was shaking one hour prior to discharge. The discharge instructions included a recommendation to not drink alcohol until the patient was re-evaluated. The patient was discharged from the facility at 11:50 AM .

An online encyclopedia defined DT's as reactions caused by alcohol or drug withdrawal after long periods of drinking. The reactions related to alcohol withdrawal are the most dangerous and can be fatal if not treated. The symptoms of DT's, which may appear suddenly, are:
-increase heart rate;
-increase blood pressure;
-agitation;
-tremors of the extremities;
-convulsions (seizure).

Review of policy #A-09-1036, titled "EMTALA-Medical Screening/Stabilization", dated 04/28/09 defined an Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain 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 (page 2, 1a). The policy also specified that a patient is stable for discharge 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 with discharge instructions (page 4, #1).

The facility failed to follow policy for Patient #2 after the patient presented to the ED requesting to be admitted to stop drinking alcohol. The patient reported he/she had a seizure, although the patient had no seizure history. The patient was discharged from the facility and did not receive stabilizing treatment for alcohol withdrawal and possible impending DT's, and did not receive a behavioral health screening from the physician to determine the patient's risk of suicide. Refer to tag A2407 for further details.

Patient #6

Review of Patient #6's closed medical record dated 02/17/11, showed the patient presented to Northeast Regional Medical Center 's ED after he/she repeatedly struck his/her head on a car and on concrete, causing self injury. The nurse documented a chief complaint of alcohol intoxication, and the nursing assessment showed the patient appeared to be extremely intoxicated with a large hematoma (injury causing blood to accumulate under the skin) on his/her forehead. The record does not indicate the patient was assessed for risk of suicide. The patient was evaluated medically, and found to have a critically high alcohol level of 254 (critical is greater than 100). The patient was discharged from the ED to jail one hour and seven minutes after arrival, without retesting the patient's blood alcohol level.

Review of policy #C-11-1041, titled "Care of the Suicidal Patient in Non-Psychiatric Facility", dated 02/11 showed that substance abuse and self-injury are risk factors for suicide. All patients receiving treatment, with a primary complaint related to an emotional or behavioral disorder or substance abuse, will be screened for risk of suicide (page 1).

Review of policy #A-09-1036, titled "EMTALA-Medical Screening/Stabilization", dated 04/28/09 showed the following:
-stable for discharge is determined when a patient has reached the point where continued care, including diagnostic testing, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with discharge instructions (page 4, #1);
-medical screening examination is an ongoing process, that monitoring should continue until the patient is stabilized, and that continued monitoring must be reflected in the medical record (page 6, #9).

During an interview on 03/02/11 at 9:00 AM, Staff A, ED physician said physicians like to see a 50 percent decrease in the alcohol level before discharging a patient.

The facility failed to follow policy for Patient #6, who presented to the facility ED extremely intoxicated with a head injury. The patient was discharged to police custody and taken to jail with a critical blood alcohol level. The patient was not stabilized or assessed for suicide risk. Refer to tag A2407 for further details.

Patient # 12

Review of Patient #12's closed medical record dated 02/20/11 showed the patient presented to Northeast Regional Medical Center ED with family. The family reported that the patient believed he/she was being followed by unknown people who wanted to hurt him/her, saw people in vivid colors, and had waved a gun around and threatened to kill himself. Nursing documentation showed the patient was intoxicated, depressed, and acted paranoid (extreme, irrational fear/mistrust of others). The nurse informed the ED physician that he/she felt the patient was dangerous and contacted local law enforcement to be prepared to respond quickly, if requested. The nurse began observing the patient closely because the patient's suicide lethality score (risk of harming self) was 124 (high is greater than 39). A blood specimen was collected for testing at 1:45 AM, which revealed the patient's alcohol level was critically high at 255 (critical is greater than 100). Shortly after the blood draw, the patient became agitated, verbally fighting with family. Throughout the stay in the ED, the patient became upset and threatened to leave the ED at 6:00 AM, but the facility failed to initiate a request for a psychiatric hold. The medical record contained documentation from two family members that completed "AFFIDAVIT[S] IN SUPPORT OF APPLICATION FOR DETENTION, EVALUATION AND TREATMENT/REHABILITATION - ADMISSION FOR 96 HOURS" describing the patient as afraid of people hurting him/her, believing he/she was being watched, and threatening to kill him/herself while waving a gun around earlier that day. The record does not contain an application for a 96 hour detention. At 5:05 AM, a mental health facility declined to admit the patient, but would reconsider the admission once the patient's alcohol level was less than 100. There are no orders to repeat the blood alcohol level in the record. At 5:55 AM, the patient demanded to leave, signed out against medical advice, and left the hospital at 6:05 AM.

Review of Policy #A-10-1037, titled "Involuntary 96 Hour Hold", dated 06/20/10 showed that "Likelihood of Serious Harm" does not require actual physical injury to have occurred and is defined as:
-risk that harm will be inflicted by a person upon his own person as evidenced by recent threats, including verbal threats, to commit suicide or inflict physical harm on him (page 1, 4a); risk that serious physical harm will result because of an impairment in his capacity to make decisions with respect to his hospitalization and need for treatment as evidenced by his current mental disorder which results in an inability to provide for his own mental health care (page 1, #4b). The policy also showed the following steps to take when requesting a 96 hour hold:
-Step One: The treating physician is responsible to provide the medical screening examination and document the findings (page 2);
-Step Two: Complete one "Application to Court for 96 Hour Detention" (page 2);
-Step Three: Complete two Affidavits in support of application for detention, evaluation, and treatment (page 2). The policy also specified that the psychiatric patient, while attempting to obtain an Involuntary hold, should remain in the hospital until the time the patient can be directly transported to the appropriate and accepting facility.

Review of policy #C-11-1041, titled "Care of the Suicidal Patient in Non-Psychiatric Facility", dated 02/11 showed the ED physician will evaluate a patient's mental health status and determine and document if the patient has an emergency psychiatric condition on the Behavioral Health Screening Tool (page 2, A).

During an interview on 03/02/11 at 12:55 PM, Physician B, ED physician said that he/she was concerned about the patient's mental health and felt the patient needed further evaluation, but forgot to document whether the patient had an emergency medical condition. Physician B said he/she did not attempt to get a 96 hour hold because there was no notary public available that night in the hospital and because the hospital cannot keep a patient from leaving.

During an interview on 03/03/11 at 9:25 AM, Patient #12's family member said an unknown ED nurse provided them with Affidavits and told them to write down everything about the patient, but that nothing was ever said about a court order to the family.

Record review of Northeast Regional Medical Center's Plan of Correction dated 02/14/11 showed that Attachment D included education to Physicians and Staff regarding EMTALA and the steps to take when a suicidal patient refuses treatment. The education showed that the ED physician and nursing staff should take steps to initiate the mental health emergency detention process through local law enforcement, if the patient poses an imminent harm to self or others.

During an interview on 03/02/11 at 1:30 PM, Staff D, Director of Security said that when a patient has a 96 hour court ordered hold in place, the Security is able to get the patient to stay "99.9 percent of the time". Staff D added that the facility has not had a psychiatric patient leave against medical advice in the past year, if they have a 96 hour court ordered hold in place.
The facility failed to follow policy for Patient #12, who presented to the facility ED after the patient showed paranoid behaviors, had hallucinations, and threatened self harm. The patient was allowed to leave the facility with a critically high alcohol level with a moderate to high risk of suicide, after the physician had clinically diagnosed the patient with psychosis (break from reality), paranoia, and alcohol abuse. There was no initiation of a 96 hour hold process to prevent the patient from leaving. Refer to tag A2407 for further details.

Based on interview, record review, and according to the statutorily mandated Quality Improvement Organization (QIO) physician peer review conducted on 03/08/11 through 03/09/11, the facility failed to stabilize three patients (Patient #2, #6, and #12) with emergency medical conditions out of 4 cases sampled from February 14 - 23, 2011. The facility Emergency Department (ED) sees an average of 1021 patients per month.

Findings included:

Patient #2

Review of Patient #2's closed medical record dated 02/14/11 showed the patient presented to Northeast Regional Medical Center's ED at 7:18 AM requesting treatment to help him/her quit drinking. The ED nurse documented that Patient #2 had been aching all over for the past 24 hours and rated the pain an 8 on a scale of 1-10. Further documentation showed the patient stated he/she had been drinking a 6 pack of beer and a fifth of vodka or whiskey daily for the past 10 years, attempted to quit drinking the previous day, and that he/she had a seizure later that night and was so agitated this morning that he/she drank a beer and took Ativan (sedative) to calm down. As documented in the medical record, the patient's behavior was inappropriate, nervous, tearful, anxious, and he/she had a flat affect. The ED nurse documented the patient was depressed, appeared thin, and that the patient felt that he/she could not eat. Further documentation showed the patient had a moderate risk of suicide per the suicide lethality rating scale (measures risk of harming self), and had an elevated heart rate and an elevated blood pressure. Documentation by the ED physician showed Patient # 2 received intravenous (in the vein) fluids, a medication to help lower Patient #2's blood pressure, and consultation with social services to arrange transfer to another facility for alcohol detoxification. At 10:50 AM, the ED nurse documented that Patient #2 had minimal shaking in her hand. At 11:08 AM, the social worker documented an attempt to arrange a transfer to another facility for inpatient detoxification, but was unsuccessful due to a lack of available beds. At 11:30 AM, the ED nurse discontinued Patient #2's intravenous fluids and provided discharge instructions. The medical record did not contain any documentation describing the patient's seizure the night prior, or an explanation for why he/she was not admitted to the hospital for care and treatment of alcohol withdrawal and possible Delirium Tremens.

An online encyclopedia defined Delirium Tremens (DT's) as reactions caused by alcohol withdrawal after long periods of drinking. These reactions are dangerous and can be fatal if not treated. The symptoms of DT's, which may appear suddenly, are:
increase heart rate; increase blood pressure; agitation; tremors of the extremities; and seizures.

Review of a hospital comparison directory showed Northeast Regional Medical Center, a teaching hospital, had the appropriate capabilities for completing a medically safe withdrawal (medical detoxification) from alcohol. The hospital's capabilities included a 16 bed intensive care unit; 115 inpatient acute- care beds and a Certified Level 3 Trauma Center.

According to the mandatory physician peer review performed by the State QIO (Quality Improvement Organization) on 03/08/2011, Patient #2 had an emergency medical condition that was not stabilized within the hospital's capabilities prior to discharge.

Patient #6

Review of Patient #6's closed medical record dated 02/17/11, showed the patient presented to Northeast Regional Medical Center's ED with law enforcement, after repeatedly striking his/her head on a car and on concrete, causing self injury while intoxicated. The nurse documented a chief complaint of alcohol intoxication, and the nursing assessment showed the patient appeared to be extremely intoxicated with a large hematoma (injury causing blood to accumulate under the skin) on his/her forehead. The ED physician examined the patient. Lab testing results revealed the patient had a critically high alcohol level of 254 (critical is greater than 100). The medical record did not contain orders to repeat the blood alcohol level. The ED physician discharged Patient # 6 from the ED to jail one hour and seven minutes after arrival and without retesting a blood alcohol level.

During an interview on 03/02/11 at 9:00 AM, Staff A, ED physician said physicians like to see a 50 percent decrease in the alcohol level before discharging a patient.

According to the mandatory physician peer review performed by the State QIO (Quality Improvement Organization) on 03/09/2011, Patient #6 had an emergency medical condition that was not stabilized within the hospital's capabilities prior to discharge.

Patient #12

Review of Patient #12's closed medical record dated 02/20/11 showed the patient presented to Northeast Regional Medical Center ED with family at 12:48 AM. The family reported that the patient believed he/she was being followed by unknown people who wanted to hurt him/her, saw people in vivid colors, and had waved a gun around and threatened to kill him/herself. Nursing documentation showed the patient was intoxicated, depressed, and acted paranoid (extreme, irrational fear/mistrust of others). The nurse informed the ED physician that he/she felt the patient was dangerous and contacted local law enforcement to respond quickly, if requested. The nurse began observing the patient closely because the patient's suicide lethality score (risk of harming self) was 124 (high is greater than 39). At 1:11 AM the ED physician examined the patient. Documentation revealed the patient was paranoid and having auditory hallucinations (hearing things that aren't real) and was aggressive during the interview (with the ED physician). The physician documented a Suicide Lethality Scale score of 33/moderate risk (a difference of 99 from the nurse's assessment) on the Behavioral Health Screening Tool. At 1:45 AM, lab testing revealed the patient's alcohol level was critically high at 255 (critical is greater than 100). At 2:10 AM the ED nurse documented Patient # 12 received a medication (Toradol) by injection for pain control and refused an intravenous device for administration of intravenous fluids. At 3:31 AM the ED nurse documented she told the ED physician that she felt Patient # 12 was dangerous, and did not feel safe alone with the patient. At 3:37 AM the ED nurse reassessed the patient and documented that family members told her a friend came to their home expressing concern for Patient # 12 ' s safety, stating the friend gave the family members a handgun that had been taken away from the patient after the patient " brandished the gun, pointing it at both the friend and at [him/herself], threatening suicide. " At 5:05 AM, the ED physician documented in the progress notes [name of psychiatric unit for a nearby acute care hospital] " declined admission due to elevated ETOH [blood alcohol level]. " " When ETOH is < 100 they would reconsider if patient still is in need of inpatient care. " The medical record did not contain orders to repeat the blood alcohol level. At 6:00 AM, the ED physician documented the " Patient decided [he/she] didn ' t want to wait. " [He/she] " will be leaving, I encouraged [him/her] to follow up outpatient (sic). " The medical record contained two " AFFIDAVIT[S] IN SUPPORT OF APPLICATION FOR DETENTION, EVALUATION AND TREATMENT/REHABILITATION - ADMISSION FOR 96 HOURS " completed by family members who brought Patient # 12 to the ED. Throughout the stay in the ED, documentation in the medical record revealed the patient became upset and threatened that he/she would stay at the facility until 6:00 AM and then leave, but the facility failed to initiate a request for a psychiatric hold.

During an interview on 03/03/11 at 9:25 AM, Patient #12's family member said an unknown ED nurse provided them with Affidavits and told them to write down everything about the patient's behavior, but that nothing was ever said about a 96 hour hold.

During an interview on 03/02/11 at 12:55 PM, Physician B, ED physician said that he/she was concerned about the patient's mental health and felt the patient needed further evaluation, but forgot to document whether the patient had an emergency medical condition. Physician B said he/she did not attempt to get a 96 hour hold because there was no notary public available that night in the hospital and because the hospital cannot force a patient to stay if the patient wants to leave.

During an interview on 03/02/11 at 1:30 PM, Staff D, Director of Security said that if a patient has a 96 hour court ordered hold; security officers are able to get the patient to stay "99.9 percent of the time". Staff D added that the facility has not had a psychiatric patient leave against medical advice in the past year, if they had a 96 hour court ordered hold in place.

According to the mandatory physician peer review performed by the State QIO (Quality Improvement Organization) on 03/09/2011, Patient #12 was allowed to leave the facility, unstable, while he/she had an emergency psychiatric condition.