HospitalInspections.org

Based on document reviews and interviews, the facility failed to ensure that two patients out of 47 emergency department (ED) records reviewed received a complete medical screening exam (MSE), that included ordered tests in order to determine whether or not an emergency medical condition (EMC) existed. The facility failed to ensure compliance with 42 CFR 489.24. Refer to citation at A-02406 for examples.




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Based on interview and record review, the facility failed to ensure three patient received a complete medical screening examination (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for two (Patient #10 and #21) out of 47 Emergency Department (ED) patient records reviewed.

Findings included:

1. Review of Patient #10's medical record showed she presented to the ED in the custody of local police on 11/13/13 at 4:03 PM, with complaints of needing a psychiatric evaluation and accompanied by an "Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation-Admission for 96 Hours" dated 11/13/13. The patient had been evaluated in jail by her therapist and the affidavit showed the patient exhibited the following behaviors:
- Has been delusional (having false or unrealistic beliefs/opinions);
- Hallucinating (false or distorted sensory experiences that appear real) that her boyfriend carves on her skin;
- Has experienced memory lapses, does not remember if or when she has taken her medication;
- Is a threat to herself with Coumadin (medication used to treat blood clots to lower the chance of blood clots from forming) because she does not take it as prescribed;
- She has shown violent behaviors;
- She has demonstrated dissociative (a disturbance of thinking, awareness, identity, consciousness or memory), delusional, hallucinations and paranoid (a thought process heavily influenced by anxiety or fear to the point of being irrational) episodes.

Review of the patient's ED Nurse's Notes dated 11/13/13 at 4:44 PM, showed Staff R, ED Staff Regstered Nurse (RN), initiated the order set for ED Psych/Alcohol Abuse/Overdose.

Review of the ED Physician's Orders showed:
- Consult to Psychiatry dated 11/13/13 at 4:44 PM;
- CBC with Auto Differential (Complete Blood Count and Automated Differential Count) dated 11/13/13 at 5:25 PM; and
- Comprehensive Metabolic Panel (CMP, a panel of 14 blood tests which serves as an initial broad medical screening tool) dated 11/13/13 at 5:25 PM.

Review of the patient's Initial Screening Assessment dated 11/13/13, documented by Staff W, Psychiatric Evaluator (an individual trained to perform a psychiatric mental health screening examination), showed:
- The patient was brought to the ED by Police with paperwork for a 96 hour hold after the patient was assessed by her therapist in jail.
- The patient reported that she was not taking her medication including Coumadin because she was running out of it.
- She denied hallucinations or suicidal ideation but showed evidence of psychotic thinking (abnormal thinking and perceptions) in the ED.
- She was cooperative for half an hour and then refused to answer any more questions.
- The patient will be discharged back to jail.
Results of the Psychiatric assessment was documented as discussed with the ED physician at 6:40 PM.

During an interview on 05/13/14 at 2:10 PM, Staff W, Psychiatric Evaluator, stated that:
-She reviewed the Affidavit for 96 Hour Hold on Patient #21 completed by her therapist stating the patient was delusional, hallucinating, and exhibiting dissociative episodes and paranoia.
- The patient was cooperative for a while then got uncooperative and paranoid.
- She had documented the patient was exhibiting psychotic behavior in the ED but her documentation was incorrect and the patient actually was not exhibiting psychotic behaviors.

Review of the ED Physician's Assessment dated 11/13/13 at 6:50 PM showed:
History of Present Illness:
- The patient refused to take her anticoagulant (medication used to prevent clotting of blood) for a clotting disorder because"No one can tell me the percentages".
- The patient is alert and oriented to person, place, time and situation with moderate distress.
-No focal neurological deficit observed.
Impression and Plan:
The patient is cooperative, depressed but stable. She has limitations related to being incarcerated by Police. The patient was counseled regarding her diagnosis, diagnostic results and treatment plan. The patient indicated understanding of instructions given.

During an interview on 05/14/14 at 1:20 PM, Staff V, Emergency Physician, stated that:
-He was not aware there was an issue with Patient #21 not taking her Coumadin.
-If he had known she had a coagulation disorder and was not taking her Coumadin he would have ordered a Protime (blood test that measures how long it takes blood to clot) and that was definitely an oversight.
-The patient could have had a medical emergency if she had coagulation problems and may have warranted an inpatient medical admission.

Review of the patient's ED medical record showed documentation that Patient #10 was not taking her Coumadin. There was no documentation that staff performed a medical assessment on the patient or laboratory test to check her bleeding time since she was non-compliant taking Coumadin.

Review of the patient's ED Nursing Discharge Summary dated 11/13/13 at 7:28 PM, showed staff documented the patient was ambulatory, discharged back to jail per Police transportation. The patient's condition at discharge was good.

2. Review of Patient #21's ED medical record showed she presented to the ED on 03/20/14 at 4:54 PM, accompanied by EMS (Emergency Medical System-Ambulance) and Police with complaints of alcohol intoxication and suicidal ideations.

Review of the ED Nurse's Notes showed on 03/20/14 at 5:50 PM, the patient presented to the ED by EMS and accompanied by local Police because she threatened suicide. EMS reported that she called her mental health physician and told him she was going to kill herself. The mental health physician called 911 to report it. The patient is to be a 96 hour hold. She is very uncooperative, belligerent and disheveled in appearance. She admitted to drinking three bottles of Vodka within a two hour time span. She is yelling and threatening staff, Police and her mental health physician. On 03/21/14 at 12:50 AM, the patient pulled out her IV (intravenous catheter-used to infuse fluids/medications directly into a vein) and stated, "I didn't think I needed it anymore." ED physician decided IV may be left out and she can come off the monitor. The patient will be allowed to sleep throughout the night.

Review of the patient's ED Physician Assessment dated 03/20/14 at 5:23 PM, showed the patient presented to the ED accompanied by Police. The patient is intoxicated and she reported that she had drank three bottles of Vodka today and had threatened to kill herself and made these threats to her physician. The degree at present is severe with risk factors consistent for alcohol abuse. The patient is alert, anxious with severe distress. She is tachycardic (heart rate over 100 beats per minute) with ranges in ER (emergency room). She is uncooperative and was restrained initially in the ER by Police with handcuffs. Impression and Plan: The patient is depressed and a suicide risk. Her condition has improved and she will be admitted. Addendum: Change diagnoses to alcohol intoxication and discharge to home after evaluation by psychiatry.

Review of the patient's Initial Screening Summary dated 03/21/14 at 12:40 AM, documented by the Psychiatric Evaluator showed the patient was brought in by EMS with a 96 hour affidavit from her therapist at CMHC. She had a blood alcohol level of 466 around 5:00 PM. The patient reported she had been threatening to kill herself if she couldn't talk to her therapist. Seven hours later she is still intoxicated but denied suicide ideation and intent. She wants to go home. Will hold her in the ER until her blood alcohol level is under 200, then she can be discharged home.

Review of the patient's laboratory report dated 03/20/14 showed her Ethanol (alcohol) level was 466 at 5:50 PM, 410 at 8:20 PM and 345 at 10:45 PM.

Review of ED Nurse's Notes dated 03/21/14 at 7:03 AM, staff documented the patient was given her drivers' license, house key and discharged to home.
The patient was discharged to home without further assessment of her ethanol level to ensure it was 200 or below.

During an interview on 05/08/14 at 10:25 AM, Staff O, ED Physician, stated that he was not aware of an ED policy that intoxicated patients will not be discharged from the hospital until their blood alcohol level is below 200. Staff O stated that he did not see being "drunk" as a medical emergency.

During an interview on 05/14/14 at 10:04 AM, Staff U, Emergency Department Director, stated that there was not a hard and fast policy for patients being discharged to home with an elevated blood alcohol.

Staff discharged the patient to home without re-assessing and ensuring her blood alcohol level was below 200. Staff did not document they re-assessed her for suicide ideations or tachycardia before she was discharged home.



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