HospitalInspections.org

Based on review of policy and procedures, EMS (Emergency Medical Services) report, County GA (Georgia) 911 Log, medical records, video surveillance, and interviews with staff, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capacity and capability of the facility, including a psychiatric examination to determine if an emergency medical condition existed for one patient (P) (#1) of 20 sampled patients.

Findings included:
Cross-refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening examination to P#1.

Based on review of policy and procedures, EMS (Emergency Medical Services) reports, County GA 911 Log, medical records, video surveillance, and interviews with staff, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capacity and capability of the facility, including a psychiatric examination for one patient (P) (#1) of 20 sampled patients. P#1 presented to the facility on 4/27/2023 via EMS at 10:30 p.m. EMS documented that P#1 was confused and agitated with a primary complaint of possible poisoning and altered mental status. P#1 eloped from the facility at 10:42 p.m. (12 minutes after arrival), prior to receiving an MSE. P#1 was returned to the ED in the care of law enforcement at 10:48 p.m. P#1 was allowed to sign out of the facility on 4/28/23 at 1:02 a.m. although documentation suggested that P#1 continued to exhibit psychotic behavior. A psychiatric consultation was not ordered on either visit as this resulted in an inappropriate medical screening examination.

Findings included:

A review of the facility's policy titled "EMTALA Transfer Policy," policy number 10848648, last reviewed 3/21, revealed in part, that "It shall be the policy of the facility that any patient who arrives at the ED or develops an emergency medical condition while at the facility shall be medically evaluated by a licensed medical provider and stabilized in accordance with EMTALA regulations. Any individual on hospital property requesting examination or treatment shall be provided with an appropriate medical screening examination."

Procedures:

Medical Screening Exam:
An individual must receive a MSE within the capabilities of the hospital's emergency department to determine whether an emergency medical condition exists.

Practitioners that may perform a medical screening exam:
Medical screening exam will be performed by a physician, or non-physician provider (PA-C, NP-C) with appropriate medical staff privileges.

Emergency Medical Condition (EMC)
A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the health of the individual in serious jeopardy
Psychological: With respect to psychiatric emergency medical conditions: History of drug ingestion in comatose or impending comatose conditions; depression with feeling of suicidal attempt or suicidal ideation; assaultive, or destructive behavior; impaired reality testing accompanied by disordered behavior; impending DT's or acute intoxication. A patient expressing suicidal or homicidal thought or gestures, if determined to be dangerous to self or others, would be considered to have an EMC.

A review of the 'Pre-hospital Care Report' (EMS) dated 4/27/23 revealed that P#1 arrived at the facility at 10:23 p.m. with a 'Primary Symptom' of 'Strange and inexplicable behavior'. Review revealed that P#1 had requested medical assistance via 911 for difficulty breathing and possible poisoning. A review of the General Assessment revealed that P#1 was confused with agitation. P#1 reported that she was being given antifreeze, and that people were trying to kill her. P#1 endorsed hearing voices. EMS documented that P#1 was highly paranoid and confused, and did not appear to have increased work of breathing. P#1's vital signs at 10:09 p.m. included: Heart rate (HR) 109 beats per minute (bpm) (normal was 60-100 bpm); respiratory rate (RR) 18 breaths per minute (normal was 14-20); blood pressure (BP) 151/91 (normal was 120/80). P#1's vital signs at 10:24 p.m. included: HR-100; RR-17; BP-129/83.

Review of the facility's video recording of P#1 dated 4/27/23 revealed at video timestamp 10:27 pm, RN BB and RN CC were observed in the nursing station at the Emergency department. At timestamp 10:42 p.m., P#1 was observed transported into the ED on a stretcher.

Visit #1. A review of the medical record revealed that P#1 arrived at about 10:30 p.m. A triage note revealed that P#1 complained of shortness of breath and chest discomfort. P#1 voiced that she may have been poisoned with rat poison. P#1 was sometimes confused but obeyed commands. Labs were ordered at 10:39 p.m. At 10:40 p.m., P#1 refused Haldol (medicine used for psychosis (mental health condition characterized by a loss of contact with reality). A suicide screening was completed that resulted in low risk (no apparent intend, or suicidal ideation). Vital signs were not recorded at this time, and an EKG was ordered and not done.

A review of the County GA 911 Log revealed that a nurse advised that P#1 ran out of the door (ED) at 10:42 p.m. At 10:48 p.m., P#1 was returned to the ED by law enforcement on 4/27/23 at 10:48 p.m.

Visit #2. Continued review of P#1's medical record revealed vital signs were taken when the patient was returned to the ED. Nursing notes revealed that it took 15 to 20 minutes to 'calm her down and she was violent towards law enforcement'. Labs were drawn and results were significant for positive amphetamines (a synthetic, addictive mood-altering drug, stimulant) and methamphetamines (Stimulant speeds up the body systems, comes in pill or powder form) the urine. A chest x-ray and EKG were performed and were negative.

PA (Physician Assistant) AA note at 11:30 p.m. revealed that P#1 was resting calmly without suicidal ideation, homicidal ideation or psychosis.

Review of the facility's video recording of P#1 dated 4/28/23 revealed at video timestamp 12:14 a.m., P#1 who was wearing a green shirt with a black jacket and had no shoes on was observed trying to enter the nursing station. Staff were observed blocking the doorway. P#1 was observed sitting on the stretcher and thereafter sat on the floor at 12:20 a.m. Sheriff deputy and security were observed approaching P#1 and taking her to the ED trauma room. P#1 was observed to be agitated and combative with the deputy and facility staff at 12:26 a.m.

Continued review of the medical record revealed discharge orders were placed by PA AA at 12:32 a.m. Orders for Ativan (a sedative) and Haldol were placed at 12:34 a.m. and 12:36 a.m. respectfully. P#1 refused the medicine stating 'Y'all are trying to poison me'. PA AA was notified of the patient's refusal. PA AA advised nursing to discharge P#1 against medical advice (AMA).

Review of the facility's video recording of P#1 dated 4/28/23 revealed at video timestamp 12:52 a.m. the deputy was observed standing at the front of trauma room where P#1 was placed. On 4/28/23 at 1:00 a.m. the deputy was observed leaving the ED. P#1 was observed leaving the ED at 1:01 a.m.

Continued review of the medical record revealed that P#1 was discharged from the ED at 1:02 a.m. Nursing documented that P#1 was noted to be confused at times at discharge. The MSE was inappropriate due to the lack of an appropriate psychiatric evaluation. Despite the patient's psychotic behaviors and the RN documenting the patient was confused at times at discharge from the hospital's ED.

The facility failed to ensure that an appropriate MSE was provided as evidenced by failing to ensure that on 4/27/2023 and 4/28/2023 Patient #1 received an appropriate MSE related to her presenting signs and symptoms of psychosis, was provided within the capability of the hospital ED to include ancillary services routinely available to the ED to determine whether or not an EMC existed. As the patient requires a psychiatric hold, and inpatient psychiatric treatment.

A telephone interview occurred with the Physician Assistant (PA) AA on 5/9/23 at 5:32 pm. PA AA explained that P#1 presented to the ED complaining of chest pain. PA AA explained that the staff completed cardiac enzymes and wanted to repeat the test two hours later, but P#1 refused further blood tests. PA AA said P#1 was not psychotic but a bit agitated. P#1 said P#1 was alert and oriented. PA AA explained that P#1 was not making any threatening statements, had no suicidal or homicidal ideation, and was not in danger to society. PA AA said he had no reason to consider placing P#1 on a 1013(involuntary admission). PA AA said P#1 refused treatment and wanted to leave the facility, so he explained the risk of leaving against medical advice to P#1. PA AA said law enforcement was called because P#1 was agitated. P #1 further explained that he does not know much about the details regarding law enforcement, and the nursing staff would better answer that.

A telephone interview took place with registered nurse (RN) BB on 5/10/23 at 10:38 am. RN BB stated she remembered P#1 being brought in by EMS for shortness of breath and chest pain. She stated P#1 came in loud and screaming "I rebuke you Satan" and would not provide her date of birth. RN BB stated she remembered PA AA ordering an electrocardiograph (EKG) and Haldol (antipsychotic used to calm patients). She stated P#1 refused the Haldol but allowed them to do the EKG and obtain blood work for labs. RN BB said that P#1 eventually left her room and ran out of the ED through the ambulance entrance doors. RN BB said three (3) staff members (herself, CNA, another RN) ran after P#1. She stated her charge nurse called law enforcement after they were unable to catch P#1. Law enforcement located P#1 at a restaurant down the street from the hospital and brought her back to the ED. RN BB stated she could not remember how long P#1 was gone. RN BB said that after law enforcement brought P#1 back to the ED, it took 15-20 minutes to calm her down, was violent towards law enforcement, in which the officer sustained a skin tear to his right arm and was confused at times. RN BB stated that after P#1 refused medication and further treatment, PA AA advised her to discharge P#1 against medical advice (AMA). RN BB stated she did not hear PA AA tell law enforcement to take P#1 to another facility for further treatment or another medical screening examination (MSE) and was shocked when she received a phone call from law enforcement advising that they were taking P#1 to another facility to be evaluated. RN BB said she could not recall receiving a phone call from the other facility once P#1 arrived because there was a lot going on at the time. RN BB acknowledged that in her clinical judgment, she believed P#1 did not have the mental capacity to make competent decisions about her care and therefore should not have been able to sign out AMA. RN BB said she did not want PA AA to find out about how she really felt about the incident and hoped her identity could be kept confidential. RN BB stated she submitted an Action Cue (incident reporting tool) detailing the events of what happened.