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Based on review of medical records, policies and procedures, and staff interview, it was determined that the facility failed to follow it's policy for reevaluation of mental health patients for one (1) of three (3) medical records reviewed (#1).

Findings were:

Review of the patient's medical record (#1) revealed the patient presented to the facility's Emergency Department (ED) at 3:00 p.m. on ED day #1 with complaints of hallucinations that the patient reportedly thought was because of a "new medication." The patient was immediately triaged (assessment by a nurse to determine the priority of need) by a registered nurse (RN). The nurse noted that the patient requested a mental health evaluation (MHE) and reported that he/she was having auditory and visual (A/V) hallucinations (hearing and seeing things). In addition, the nurse noted that the patient reported having a change in sleep pattern, insomnia (difficulty sleeping), decreased hygiene, and poor impulse control for one (1) day. The nurse noted that the patient denied suicidal thoughts, had an inappropriate mood, was agitated, loud, anxious, crying, and had an irrational thought process.

Physician notes revealed the patient was evaluated by the physician at 3:17 p.m. The physician noted that the patient was agitated and reported a sudden onset of A/V hallucinations for one (1) day. The physician noted that the patient reportedly had recently been discharged from a Methadone (opiate drug addiction) clinic. The initial physician orders included a mental health consultation, blood work, a urine drug screen, and Haldol (antipsychotic medication) 10 milligram (mg) intramuscular (IM - injection administered into the muscle). Nurses' notes revealed the Haldol was administered at 3:36 p.m.

The mental health consultation was performed at 3:30 p.m. The counselor noted that the patient reported that the A / V hallucinations were telling him/her to "die." The counselor noted that the patient had a family history of suicide and that the patient reported having thoughts of suicide due to the commands to "die." At 3:50 p.m., review of the nurse's notes revealed the patient's family had been updated as to the patient's care. At 4:30 p.m., the physician signed a 1013 (State of Georgia's legal document that allows a patient to be held involuntarily for 72 hour when the patient present a danger to themselves or others). Nursing documentation revealed that a security guard was placed outside the patient's room to monitor the patient during the entire time the patient was in the ED.

At 5:34 p.m., the nurse noted that a local psychiatric facility had been contacted and a request to transfer the patient to the facility had been denied. At 6:05 p.m., the nurse noted that the counselor was trying to assist the facility with the patient's transfer. At 7:58 p.m., the nurse noted that the patient was informed of his/her status. At 8:52 p.m., the physician reassessed the patient and noted that the patient was awaiting acceptance to one of the state psychiatric facilities.

On ED day #2 at 1:06 a.m., the nurse noted that the patient walked to the nursing station and requested something for sleep and was informed that the physician would not order a sleep aid because the patient had been sleeping for several hours. At 2:16 a.m., the nurse noted that the patient was updated on his/her status. At 5:11 a.m., the nurse noted that the State psychiatric facility was pending a physician's review and acceptance of the patient. At 8:30 a.m., the physician ordered and the patient received Celexa (antidepressant medication) 20 mg by mouth. At 9:42 a.m., the nurse noted that the State psychiatric facility had accepted the patient but were not ready for the patient to be transported. At 10:11 p.m., the nurse noted that the patient was awaiting transfer.

On ED day #3 at 2:23 a.m., the physician ordered and the patient received Ativan (antianxiety medication) 1 mg by mouth now. At 6:40 a.m., the physician ordered and the patient received Celexa 20 mg by mouth. At 7:16 a.m., the nurse noted that the patient was in the hall talking on the telephone and was calm and cooperative. At 10:56 a.m., the nurse noted that the patient came to the nursing station requesting something for a headache and was given Ibuprofen (medication used to treat pain) 600 mg. At 12:25 p.m., the nurse noted that the security guard was periodically taking the patient outside to smoke and that the patient was calm and cooperative. At 11:12 p.m., the nurse noted that the patient questioned when the 1013 would expire and was informed that the 1013 would expire the next day at 4:30 p.m. if the patient had not been transferred or reordered by the physician. The nurse noted that the patient verbalized understanding. At 11:28 p.m., the nurse noted that the State psychiatric facility called and informed the staff that the patient could arrive at the facility at 9:00 a.m. the next morning.

On ED day #4 at 6:43 a.m., the physician ordered and the patient received Celexa 20 mg by mouth. At 6:45 a.m., the nurse noted that the patient was updated on his/her status. At 7:09 a.m., the nurse noted that the patient was taken outside to smoke by the security guard. At 7:21 a.m., the physician ordered and the patient received Ativan 1 mg by mouth. At 7:32 a.m., the nurse noted that the patient was calm, cooperative, and knew he/she would be transferred at 8:00 a.m. At 12:19 p.m., the transfer form revealed the patient was transferred to the State psychiatric facility in stable condition. The form noted that the risks and benefits were explained to the patient and that the patient was released to the local Sheriff's Department to be transported to the state psychiatric facility. There was no additional documentation of the patient being re-evaluated by a physician on ED days #2, 3, or 4. There was also no copy of the facility's standing Psychiatric Holding Orders in the patient's medical record.

Review of facility"s policy entitled "Mental Health Patients", policy # 11-II:054, last revised 03/10/10, required patients held in the ED because the accepting facility had no available bed to be assessed and daily and as needed by the ED physician. This policy also required the physician to activate the Psychiatric Holding Orders. In addition, the policy required the staff to have the patient re-evaluated by a mental health counselor after 48 hours.

During an interview at 9:00 a.m. on 08/25/10 in the Conference Room, the Assistant Administrator of Patient care Services (interview #1) stated that the facility contracted with a local psychiatric facility to do the mental health consultations. He/she said that the facility did not provide psychiatric services.

During an interview at 11:30 a.m. on 08/25/10 in the Conference Room, the Licensed Practical Nurse (LPN - interview #2) stated that he/she had initially provided nursing care for the patient. The nurse stated that the patient had been anxious and hallucinating. The nurse also stated that he/she had not heard the patient threaten himself/herself or others.

During a telephone interview at 12:15 p.m. on 08/25/10 in the Conference Room, the Director of Admissions (DOA) for the local psychiatric facility stated that he/she was a Licensed Clinical Social Worker (LCSW interview #3). The DOA explained that he/she supervised the mental health counselors. The DOA stated that the counselor who had evaluated the patient was out of town and not available for an interview. The DOA further stated that he/she had spoken with the patient's family member and had explained the patient's 1013 status.

During an interview at 12:30 p.m. on 08/25/10 in the Conference Room, the Physician (interview #4) stated that he/she was not the physician who signed the 1013 but that he/she had also provided care for the patient. He/she explained that the patient had not reported suicidal thoughts to him/her. The physician stated that when a patient was held on a 1013 the physician would keep an eye on the patient and if something occurred the physician would go in and see the patient.