HospitalInspections.org

Based on review of Medical Record (MR), facility policies and procedure and staff interviews it was determined Troy Regional Medical Center (TRMC) failed to ensure:

1. Staff implemented steps to prevent a patient evaluated as a danger to self or others with recommended acute psychiatric hospital placement from leaving the facility prior to being transferred to receive stabilizing treatment the facility did not have the capability to provide.

2. Patient's legal representative was informed of the possible risk of leaving Against Medical Advice (AMA) by a qualified medical provider.

3. The Emergency Department (ED) staff followed the facility procedure for proper transfer of a pregnant patient.

4. Documentation of the Facility to Facility Transfer Record Form was completed and in the transferred patient's MR.

5. The transferring physician certified the medical benefits of the transfer outweighed the risks to the patient and included a summary of the risk and benefits of the transfer.

6. The transferring physician determined the appropriate mode, equipment and attendants for transfer.

7. Consent was signed by the patient giving TRMC permission to transfer the patient.

8. All MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent the receiving facility.

Findings Include:

Refer to A 2407 and A 2409 for findings.

Based on review of facility policy and procedure, medical records (MR), and interview with staff, it was determined the facility failed to:

1. Ensure the staff implemented steps to prevent a patient evaluated as a danger to self or others with recommended acute psychiatric hospital placement from leaving the facility prior to being transferred to receive stabilizing treatment the facility did not have the capability to provide.

2. Ensure the patient's legal representative was informed of the possible risk of leaving Against Medical Advice (AMA) by a qualified medical provider.

This deficient practice affected 1 of 3 MR's reviewed with a Psychiatric Problem who left AMA, including Patient Identifier (PI) # 16 and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings include:

Facility Policy: Informed Refusal and Elopement
Effective Date: 12/13/19

...Purpose; To provide guidelines for hospital staff when a patient or the patient's legal representative on behalf of the patient elects to leave the facility AMA... This policy is in place to provide the safest care to patients...and to educate all patients on the possible risk of leaving before disposition by a qualified medical provider.

...Procedure: ...When a patient requests to leave the facility prior to discharge by a qualified medical provider or contrary to the advice of the qualified medical provider, the nursing staff should notify the attending provider immediately. The licensed nursing staff must inform the patient that the attending qualified medical provider will inform the patient of the consequences and risks of leaving the facility....

PI # 16 presented to the facility ED on 9/23/21 at 2:10 PM with a chief complaint of Psychiatric Problem.

Review of the Triage Assessment dated 9/23/21 at 2:21 PM revealed nursing documentation of "presents with (mother/father) who states that child has been acting out for approximately 3 weeks. (Mother/Father) states that one hour ago the child picked up...diabetes and blood pressure medicine and acted like (he/she) was going to take it to try and kill (himself/herself), as well as acting like (he/she) was going to cut (himself/herself) with a kitchen knife... 20 minutes PTA (prior to arrival), the child put a rope around (his/her) neck and put it out the car window trying to and (himself/herself)....states '(he/she) needs to go somewhere'..."

Review of the Nursing Assessment dated 9/23/21 at 2:50 PM revealed documentation the patient was crying, smiling, in mild distress, attentive, combative, oriented to person, place and time, with an angry, anxious, violent and normal affect.

Review of the Psychiatric Evaluation dated 9/23/21 at 5:00 PM revealed documentation of "client is having auditory hallucinations. (He/She) stated (he/she) has command hallucinations and they place (himself/herself) and others in danger. Recommend placement in an acute psych (psychiatric) hospital."

Review of the Nursing Notes dated 9/23/21 revealed nursing documentation of the following:

At 3:30 PM, "upon entering room to initiate ordered lab work... (Mother/Father) at bedside states, 'I need yall to call DHR (Department of Human Resources) and the police because I can't stay here with (him/her) this whole time. I have another autistic child at home and a (grandfather/grandmother) and I can't stay here with (him/her) for what could be two hours or more. I explained to (mother/father) that a guardian was needed at bedside at all times due to patient being a minor, (mother/father)...states 'that's fine but I'm not staying, yall need to call DHR and the police so I can hand (him/her) over to their care because I can't and won't be staying here, don't tell me what I can and can't do..." The Police Department was documented as in the ED on 9/23/21 at 3:38 PM and spoke with the mother/father at 3:45 PM. There was no documentation of the conversation with the police.

At 3:50 PM, the nurse was attempting to obtain labs when the patient became scared requesting the parent. The parent was behind the bed on the phone and the nurse asked the parent multiple times to come around so the patient could see the parent to help the patient relax. The parent remained on the phone and refused. The patient then began crying and stated, "if I do this will you not take my (parent identified) away. (Mom/Dad) states, they are (aren ' t') taking me away they are taking you away. Pt informed we were not wanting to take (mom/dad) away just want (him/her) to get help. Pt is crying, (mom/dad) has yet to show any affection towards child and remains on phone. (Mother/Father) is on phone asking someone to get her bank card and her other child and take it to her (grandparent identified) so (she/he) can get bailed out. (Mother/Father) states, 'they can take (him/her), but they aren't taking both of my kids or my (dad/mom). Don't no body want (him/her).' I asked (mother/father) to please keep those comments to (herself/himself), (he/she) was a child and could hear...(mother/father) states, it was the truth..." The nurse continued to documented the parent called the police department due to the facility telling the parent since the patient was a minor child the parent would need to remain with the patient in the ED. The nurse documented the parent "...showed no concern or care for the care of the patient. No attempts to help nurses calm patient. Pt did yell during the blood draw and arms were held by nursing to obtain blood. Pt yelled, 'you ugly bitches.'..."

At 3:50 PM, a second nurses documented of the patient appeared upset and scared due to the labwork and was yelling for the parent who was on the phone. The nurse documented multiple attempts were made to have parent come in sight of patient with the parent stating, "(he/she) can see me fine over here." The nurse documented, "patient continues to yell for (mother/father) and yells 'stop bitch, stop sticking me. I'm gonna kill you.'..."

At 3:59 PM, the patient was sitting on the side of the bed away from the parent, who remained on the phone, crying.

At 4:00 PM, the parent was at the bedside on the phone stating, "...get my bank card cuz (because) the police tryin (trying to) take me if I leave and I know I'm about to leave so I know I need to bail out..." while the patient was sitting on the side of the bed crying.

At 4:05 PM, the patient was standing at the side of the bed kicking the bed and screaming at the parent who was not responding.

At 4:07 PM, the patient was screaming and attempted to run out of the room. The patient was stopped by the facility staff and moved to another room away from the parent when the patient stated, "I don't want to be around my (mama/daddy) anymore, (she/he) doesn't pay attention to me..."

At 4:10 PM, the patient was administered Ativan 2 milligrams (mg) orally.

At 4:13 PM, the patient told facility staff he/she felt safe at home and denied physical abuse but stated "my (mama/daddy) just doesn't love me and doesn't want me to live with (her/him), (she/he) is always telling me that and is picking on me....pt continues to cry and state, 'my (mama/daddy) just doesn't love me, I try my best and try to help (her/him)."

Review of the Physician Note dated 9/23/21 at 2:33 PM revealed documentation of "chief complaint of psychiatric problem...onset was just prior to arrival. The patient is experiencing hallucinations described as auditory hallucinations and tactile hallucinations. The patient is not able to care for him/herself. The patient is not able to control him/herself... The patient currently presents with unclear thinking, violent behavior and bizarre behavior. The patient currently admits to suicidal ideation and homicidal ideation. The patient admits to planning an overdose and hang (himself/herself). Current stressors include family.... presents to ED for violent bizarre behavior along with auditory hallucinations. Pt is very angry and (mother/father) is unwilling and uninterested in assisting with the situation or comforting the child. There was concern/mixed statements on whether child took family members prescription medication...History of Attention Deficit Hyperactivity Disorder, Anxiety and Suicidal attempt(s), ODD (Oppositional defiant disorder); Bipolar; Autism...Thought was delusional. Affect was angry and hysterical. There were auditory hallucinations. Insight was below average. Judgement was below average..."

Further review of the Nursing Notes dated 9/23/21 revealed nursing documentation of the following:

At 7:01 PM, "DHR at bedside...patient became combative and agitated, shouting and attempting to leave room...continues to yell and scream absurdities at nursing staff."

At 7:02 PM, the police department was notified.

At 7:08 PM, the patient was administered Ativan 2 mg Intramuscular (IM) injection (inj).

At 7:14 PM, "attempt to calm patient prior to Ativan inj without success. It took 5 staff at bedside to keep patient in bed and not run out of room. Patient continues to scream absurdities screaming, 'I don't give a fuck, I'm tired of all this.' "

Further review of the Nursing Notes dated 9/23/21 revealed nursing documentation of multiple attempts to obtain placement at another facility to transfer the patient without success.

Review of the Nursing Notes dated 9/24/21 revealed nursing documentation of the following:

At 12:44 AM, the parent was sitting at bedside and requested medication to help the patient relax. Upon the nurse entering the room, "...pt was laying half on the bed and half off...pt eyes were closed and...responded after a few seconds of saying (his/her) name. (Mother/Father) states...wants to go to the car and get medication to help (him/her) relax. RN (Registered Nurse) explained...that pt had medication that will help...and when I was just in the room the pt was laying half off the bed passed out. (Mother/Father) was at bedside when pt was laying off the side. (Mother/Father) states... 'needs something to help (him/her) relax, because (parent identified) is starting to get upset.' Pt is laying in bed with pillow and blanket quiet..."

At 8:45 AM, Geodon 20 mg and Ativan 2 mg were administered IM.

At 8:49 AM, "patient is now cursing at staff and throwing drinks - unable to redirect..."

At 10:00 AM, "patient's (mother/father) yelling at staff and stating, 'I can't be staying here for 2 or 3 days - Y'all gonna pay my bills.' Attempts to calm mother unsuccessful..."

Further review of the Nursing Notes dated 9/24/21 revealed nursing documentation of multiple attempts to obtain placement at another facility to transfer the patient without success.

Review of the Physician Note dated 9/24/21 at 1:36 PM revealed documentation of "restless in the room/medicated Ativan-Geodon."

Review of the Nursing Notes dated 9/25/21 revealed nursing documentation of the following:

At 8:44 AM, the patient's parent verbalized she/he needed to go to work and "...cannot miss any more work d/t (due to) this..."

At 8:45 AM, "pt's (mother/father) screaming on the phone that...can (can't) stay up here all weekend...has to work...'I'll just leave and they call the cops and I'll bond out of jail and they can deal with (him/her). This is ridiculous that (he/she) has been here for this long and they aren't doing anything for (him/her)'"

At 8:46 AM, "pt's (mother/father) yelling at someone on the phone...door was closed for approx (approximately) 45 sec (seconds), pt could be heard screaming and crying...pt exited the room away from...(mother/father)...see note below regarding pt exiting the building. "

At 9:06 AM, "pt exited the back door of the ER (Emergency Room) with PCT (Patient Care Technician) sitter and myself following; pt does not stop when asked, is pushing away from PCT; informed PCT to keep eyes on pt while I got security to come out; Security officer walked out of building and instructed...to stay with pt and PCT while I called...PD (Police Department) for assistance. "

Further review of the Nursing Notes dated 9/25/21 revealed the patient remained calm and cooperative following the nursing documentation at 9:06 AM and nursing documentation of multiple attempts to obtain placement at another facility to transfer the patient without success.

Review of the Physician Note dated 9/25/21 at 9:15 AM revealed documentation of "restless inside small room now x 3 days..."

Review of the Nursing Notes dated 9/26/21 revealed the patient remained calm and cooperative throughout the day.

Review of the Psychiatric Reevaluation dated 9/25/21 at 10:37 AM revealed documentation of "client is displaying erratic and potentially self harming behavior, ex: (example) picking large pieces off wall and tried to eat it. It is recommended he remain in acute psyche (psychiatric) hospital placement until In-patient acute is available."

Review of the Nursing Notes dated 9/27/21 revealed nursing documentation of the following:

At 8:48 AM, the parent was on the phone in the patient's room "...loudly stating to pt psychiatrist on the phone 'they have us in this little room and wont let us leave, they wont get us a room or let us have a room anywhere; - and '(he/she) aint got no tv...has to use they bathroom and they shower...(mother/father) stating that psychiatrist states to discharge pt for follow up with (him/her), (mother/father) informed that pt psychiatrist will need to speak with (facility ED physician identified) regarding change in plan of care and...recommendations - (mother/father) verbalizing discontent and continues to speak with psychiatrist..."

At 9:51 AM, the parent was "...crying at bedside states, 'I am going to follow up with...pediatric psychiatrist to change medications.' (Mother/Father) wants to leave AMA. States (she/he) understands the risk of leaving and benefits of staying. Pt is calm and cooperative at this time...denies Homicidal or Suicidal thoughts... DHR notified of patient...leaving AMA and will follow up. (Mother/Father) and child seem to be bonding at this time and more compassion noted from (mother/father). Child states (he/she) wants to leave with (mother/father)..."

At 10:02 AM, "Notified...at (Mental Health Center identified) of (mothers/fathers) choice to sign pt out AMA. Request follow up with patient as potential outpatient."

Review of the Discharge Disposition dated 9/27/21 at 9:52 AM revealed nursing documentation the facility ED physician was notified of parent's wish to sign out AMA and the parent signed the patient out AMA.

Review of the AMA form revealed the signatures of the parent and the ED nurse dated 9/27/21 at 9:45 AM.

Review of the MR revealed no documentation the facility took steps to prevent a patient who was evaluated as a danger to self or others with recommended acute psychiatric hospital placement from leaving the facility prior to being transferred to receive stabilizing treatment the facility did not have the capability to provide. There was no documentation the patient's legal representative was informed of the possible risk of leaving AMA by the physician.

An interview was conducted on 10/27/21 at 11:29 AM with Employee Identifier # 1, Chief Nursing Officer, who confirmed there was no documentation the facility took steps to prevent a patient from leaving the facility AMA nor the patient's legal representative was informed of the possible risk of leaving AMA by the physician.

Based on review of Medical Record (MR), facility policies and procedure and staff interviews it was determined Troy Regional Medical Center (TRMC) failed to ensure:

1. The Emergency Department (ED) staff followed the facility procedure for proper transfer of a pregnant patient.

2. Documentation of the Facility to Facility Transfer Record Form was completed and in the transferred patient's MR.

3. The transferring physician certified the medical benefits of the transfer outweighed the risks to the patient and included a summary of the risk and benefits of the transfer.

4. The transferring physician determined the appropriate mode, equipment and attendants for transfer.

5. Consent was signed by the patient giving TRMC permission to transfer the patient.

6. All MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent the receiving facility.

This deficient practice did affect 1 of 4 patients who were transferred from the facility, including Patient Identifier (PI) # 2 and had the potential to affect all patients presenting to the facility ED who would require a transfer to another facility.

Findings include:

Facility Policy: Transfer of Patient Within and Outside the Hospital
Revised Date: November 11, 2010

Purpose:

To provide a guideline for safe and consistent transfer of patients to...facilities outside the facility.

Procedure:

Transfer to Another Facility:

1. Ensure physician order is on chart including the accepting physician and facility, and the means by which the patient should be transported BLS (basic life support) ACLS (Advance Cardiac Life Support).

2. Inform patient/family of transfer. Complete transfer form and have consent form signed by the patient and physician.

Means of transfer will be ambulance service of patient's choice or helicopter transfer as deemed by transferring physician and accepting physician.

Facility Policy: Administrative Policy concerning EMTALA (Emergency Medical Treatment and Labor Act)
Effective Date: 3/25/2020

...IV. Appropriate Transfers

...2. Physician Certification. The Physician Certification must be in writing, signed by a physician...certify that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the risks to the individual (or, in the case of a pregnant woman...to the woman and her unborn child) from being transferred and include a summary of such risk and benefits...

...B. Appropriate Transfer...

...3. Medical Records...TRMC must send to the receiving facility all MRs related to the transferred individual's EMC (Emergency Medical Condition) available at the time of transfer...

4. Qualified Transfer Personnel and Equipment. TRMC must carry out the transfer using qualified personnel and transportation equipment, including any necessary and appropriate life support measures, as required to effect the transfer. The treating physician at TRMC has the responsibility to determine the appropriate mode, equipment and attendants for transfer...

1. Hospital A Troy Regional Medical Center Documentation

Patient Identifier (PI) # 2 presented to the ED on 4/26/21 at 10:37 PM with a complaint of being in labor.

Review of the triage note dated 4/26/21 at 10:48 PM revealed documentation PI # 2 was 32 weeks gestation. PI # 2 stated the symptoms came on suddenly, the pain was unchanged since the onset, was irregular and occurred every 10 minutes with fetal movement being normal. The location of the pain was diffused and suprapubic with the severity of pain at a 4 on a 0 to 10 scale. There had been vaginal bleeding with the onset of pain. The patient was a gravida 3 para 2 and abortus 0. The triage acuity was documented as 3 Urgent.

Review of the ED physician documentation on 4/26/21 at 10:58 PM revealed documentation the chief complaint was labor. PI # 2 was 32 weeks pregnant with abdominal contraction pain every 5 minutes times 3 hours with no bleeding or discharge. The symptoms came on gradually and the pain occurred every 5 minutes. Fetal movement had been normal. The quality of the symptoms were described to be cramping and the severity of pain was mild. The patient was a gravida 3 para 2 and abortus 0. The physical exam revealed externally negative for clear fluids and no vaginal bleeding was present. The cervix was 0 centimeters dilated and no cervical effacement and no uterine tenderness.

Review of the nursing assessment dated 4/26/21 at 11:08 PM revealed documentation PI # 2 was pregnant, symptoms came on suddenly and the pain was unchanged since onset. The pain was irregular and occurred every 10 minutes and fetal movement has been normal. The duration of pain had been transient and the severity of pain was at 4. There had been vaginal bleeding and no fluid leakage. The patient is a gravida 3, para 2, abortus 0 and the gestational age was 32 weeks and PI # 2 presented complaining of pelvic pain and contractions. Fetal heart tones were 156 beats per minute.

Review of the physician documentation dated 4/26/21 at 11:27 PM revealed discharge instructions given to the patient to follow up with provider. PI # 2 was discharged to go to L-D (Labor and Delivery) at Hospital B, receiving hospital. Upon discharge from Hospital A, PI # 2's condition was good. Education was provided for the prognosis and need for follow-up third trimester of pregnancy with provider.... PI # 2 was discharged to Private Owned Vehicle (POV) to Hospital B.

Review of the nursing treatment notes dated 4/27/21 at 12:09 AM revealed Hospital B, Receiving Hospital, transfer line staff spoke with the ED nurse and gave instructions to send PI # 2 per POV to Hospital B and check in at the OB (Obstetric) triage they are waiting on the patient.

Review of the ED Physician documentation dated 4/27/21 at 12:13 AM revealed the on-call OB/GYN (Obstetrician and Gynecologist) for Hospital B accepted the patient.

Review of the nursing discharge documentation on 4/27/21 at 12:26 AM revealed PI # 2 was discharged by POV to Hospital B in good condition, with a pain scale of 0 on a 1-10 scale, and provided education on follow-up care and safety issues.

Review of the MR revealed no documentation the patient consented to the transfer, the transferring physician certified the medical benefits of the transfer outweighed the risks to the patient and included a summary of the risk and benefits of the transfer, the transferring physician determined the appropriate mode, equipment and attendants for transfer, PI # 2's MR was sent to Hospital B, and a transfer form was completed.

An interview was conducted on 10/27/21 at 11:20 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, who stated when a patient is discharged from there ED and is going by Private Owned Vehicle, no transfer paperwork was completed.

Hospital B Baptist East

PI # 2 presented to the OB triage check in at Hospital B on 4/27/21 at 1:31 AM for follow up of possible labor contractions. PI # 2 was taken to the Labor and Delivery area where a Fetal Heart Tone (FHT) monitor was placed on the patient and an exam was conducted. FHT were 140 with no decelerations. PI # 2 was not having contractions while at Hospital B per the examination conducted. At 3:10 AM on 4/27/21 FHT again were checked per the nurse and were documented as 135, PI # 2 was asleep. At 3:25 AM the nurse woke PI # 2 who stated she only had mild back pain and felt comfortable being discharged home. Discharge instructions were given and PI # 2 was discharged.