HospitalInspections.org

Based on interview and record review, the facility failed to follow their policies and procedures and did not provide the necessary stabilizing treatment for an Emergency Medical Condition on one patient (#1), within the facility's capabilities and capacity. This occurred for one patient (#1) out of 30 Emergency Department (ED) patient medical records reviewed from June 2013 to December 2013. The facility census was 223, the average daily ED census over the past six months was 113 and the average monthly ED census over the last six months was 3392.

Findings included:

Review of the facility policy titled, "Management of Psychiatric patients in RMC Emergency Department" revised 09/2015 showed the following information:
-RMC will assess all patients for problems with substance abuse or dependence, mental disorders or potential for harm to self or others and will provide care and follow-up.
-If patient presents with a clear psychiatric condition which requires admission (SI, HI, etc), the ED physician will contact the psychiatrist on call for the Emergency Department for Admission. The ED physician is responsible for providing stabilizing treatment for the patient prior to admission or transfer.
-All Patients requiring transfer because the inpatient psychiatric unit does not have the capacity or capability will be transferred to another psychiatric facility via EMS or Security and Hospital personnel. No patient will be transferred via personal vehicle.

Review of hospital policy, Admission to 7W - Criteria and process" reviewed 05/2013, showed that each patient must be assessed, evaluated and given a diagnosis before he/she may be admitted to the 7 West Behavioral Health Unit (BHU). The Emergency Physician and the 7 West BHU on call psychiatrist or the patient's personal psychiatrist will determine the appropriate course and give the order for admission. The policy described below showed the hospital had the capability to provide stabilizing treatment to patient # 1, who presented to the ED on 12/16/13 at 1:53 PM.

A. Inpatient admission criteria include (but are not limited to):
1. Threat to self- requiring 24-hour professional observation
a. Suicidal ideation or gesture within 24 hours prior to admission
b. Self- mutilation (actual or threatened) within 24 hours prior to
admission
c. Chronic and continuing self -injurious behavior that poses a significant
and/or immediate threat to life, limb, or bodily function.
2. Threat to others requiring 24-hour professional observation:
a. Assaultive behavior threatening others within 24 hours prior to
admission.
b. Significant verbal threat to the safety of others within 24 hours prior to
admission.
3. Command hallucinations directing harm to self or others where there is the
risk of the patient taking action on them.
4. Acutely disordered/bizarre behavior or psychomotor agitation that interferes
with the activities of daily living (ADLs) so that the patient cannot function at a
less intensive level of care during evaluation and treatment.
5. Cognitive impairment (disorientation or memory loss) due to an acute Axis I
disorder that endangers the welfare of the patient or others.
6. Patients with a dementia disorder who need evaluation or treatment of a
psychiatric co-morbidity e.g., risk of suicide, violence, severe depression)
warranting inpatient admission.
7. A mental disorder causing major disability in social, interpersonal,
occupational, and/or educational functioning that is leading to dangerous or
life-threatening functioning, and that can only be addressed in an acute
inpatient setting.
8. A mental disorder that causes an inability to maintain adequate nutrition or
self-care, for which family/community support cannot provide reliable,
essential care, so that the patient cannot function at a less intensive level of
care during evaluation and treatment.
9. Failure of outpatient psychiatric treatment so that the patient requires 24-hour
professional observation and care. Reasons for the failure of outpatient
treatment could include:
a. Increasing severity of psychiatric symptoms;
b. Noncompliance with medication regimen due to the severity of
psychiatric symptoms;
c. Inadequate clinical response to psychotropic medications;
d. Due to the severity of psychiatric symptoms, the patient is unable to
participate in an outpatient psychiatric treatment program.
10. Other conditions may be present:
a. A recent weight loss/gain refractory to aggressive outpatient or partial
hospitalization therapy;
b. Mental Disorder refractory to a thoroughly documented effort at
aggressive outpatient or partial hospitalization (e.g. recurrent
psychosis not responsive to outpatient treatment, severe depression.
Or failing to respond to (21) days of outpatient drug therapy;
c. Toxic effects of therapeutic psychotropic drugs;
d. Introduction of, withdrawal from or change in dose of
psychotherapeutic medication(s), in cases in which there is strong
reason to believe that potentially serious side effects are likely to
occur( e.g. due to high doses and/or co-concomitant cardiac disease
known to be sensitive to the drugs in question).

Review of the December 16, 2013 Daily Bed Management sheet for 7 West BHU showed there were 18 occupied beds out of 25, and one confirmed pending discharge and 3 potential discharges.

Review of a closed medical record showed Patient # 1 presented to the facility's emergency department (ED) by ambulance on December 16, 2013 at 1:53 PM. Documentation sent from the Nursing Home (NH) where patient # 1 resided included two affidavits to support admission for 96 hours. The affidavits showed patient # 1 had become hostile, assaulted nursing home staff, threatened to elope, would not redirect, and was "clearly a danger to himself and potentially other residents." At 2:00 PM the ED nurse documented patient # 1 stated he "is being manipulated at the NH." Further documentation revealed patient # 1's past medical history included Schizophrenia (chronic, severe, and disabling mental illness), Bi-polar disorder (a mental illness that causes shifts in mood, energy, and ability to function), Anxiety, and High Blood pressure. At 2:15 PM the ED physician examined patient # 1 and documented the patient had been involved in an altercation prior to arrival, that a family member was the patient's durable power of attorney (DPOA) who arranged commitment to long-term care for his schizoaffective personality disorder, that the patient seemed "somewhat tangential (irrelevant responses), and religiously preoccupied", but denied SI/HI (suicidal ideation, homicidal ideation), and that the patient had been discharged from the behavioral health unit on 7 West February 2013. At 2:32 PM the ED nurse documented a sitter was assigned to closely monitor patient # 1 after he attempted to leave the ED and that security was summoned to encourage the patient to remain in his room. Further documentation showedt the ED nurse administered to patient # 1 an intravenous dose of an anti-anxiety medication (Ativan). At 2:35 PM the Licensed Professional Counselor (LPC) interviewed patient # 1 and documented the patient was mildly paranoid with fair insight and judgment. The LPC documented conferring with the on call psychiatrist who determined the patient did not meet clinical criteria for inpatient psychiatric hospitalization. At 4:03 PM the ED nurse documented patient # 1 became increasingly agitated and hostile after being told he would be discharged back to the nursing home and that Patient # 1 screamed at staff and pulled out his intravenous (IV) catheter while verbally and physically assaulting ED staff. The ED nurse completed an affidavit to support admission for 96 hours. The affidavit documentation showed patient # 1 became upset and forcefully pushed his sitter into the corner of the room while screaming "get out of my face." At 3:55 PM patient # 1 received an injection of an antipsychotic medication (Geodon). At 5:54 PM the ED physician documented he spoke with the on call psychiatrist who requested patient # 1 be admitted to Hospital B. ED staff documented on the transfer form patient # 1's "Medical Condition: Diagnosis: [was] Agitation" and that the patient would be transported by ambulance to Hospital B. The space on the transfer form for "Support/Treatment during transfer" included a blank space for "Restraints - Type or Other." The medical record did not contain evidence that the hospital processed an involuntary commitment or stabilized patient # 1's psychiatric emergency medical condition within its capabilities or capacity and did not arrange admission to the psychiatric unit on 7 West. Review of patient # 1's prior 7 West medical record dated February 1 - 28, 2013 (and reviewed by the ED physician on 12/16/13) showed the patient had threatened to kill self and exhibited assaultive behavior towards staff early in his admission. Further documentation in the 7 West February 2013 medical record showed patient # 1 had a long history of psychiatric illness and had been hospitalized multiple times.

Review of the December 16, 2013 ambulance report showed patient # 1 left the ED at 7:29 PM and was seated in the ambulance with the seat belt fastened for transport to Hospital B. Further documentation showed the ambulance arrived at Hospital B at 7:33 PM and that an ambulance crew member observed patient # 1 walk out of the front door of Hospital B after refusing to fill out the intake form.

During a telephone interview on January 6, 2014 at 3:13 PM, emergency medical technician (EMT) X stated that dispatch sent them a non-emergency transport from Research Medical Center to Hospital B. He stated that the ED nurse did not tell them of the patient ' s prior elopement attempt and he did not remember being told the patient had pushed the ED technician (tech). He stated that he and his partner had walked the patient into Hospital B but his partner then left and went back to the ambulance. He stated that had they known of the elopement attempt and the violence in the ED, they both would have stayed with the patient.

During an interview on December 23, 2013 at 4:03 PM, the Director of Risk Management (Staff B) stated Research Medical Center does not have a policy which dictates how a patient was to be transported out of the ED with EMS personnel.

During a telephone interview on December 26, 2013 at 10:45 AM, nurse S at Hospital B stated she received report from ED nurse J and that the patient would be transported by ambulance to their hospital. She stated she was told the patient had been agitated at the NH where he lived and had thrown a medication cart. She stated she was told he became a little combative with staff, security had been called, and that the patient had been medicated and was now calm and cooperative. She stated she had not been told he tried to elope or that he had become physically abusive while in the ED.

Based on interview, record review and policy review, the hospital failed to provide stabilizing treatment within its capacity and capability for one patient (#1) out of a sample selected from June through December 2013. The Emergency Departments average daily census is 113 and average monthly census is 3392.

Findings included:

Review of the facility policy titled, "Management of Psychiatric patients in RMC Emergency Department" revised 09/2015 showed the following information:
-RMC will assess all patients for problems with substance abuse or dependence, mental disorders or potential for harm to self or others and will provide care and follow-up.
-If patient presents with a clear psychiatric condition which requires admission (SI, HI, etc), the ED physician will contact the psychiatrist on call for the Emergency Department for Admission. The ED physician is responsible for providing stabilizing treatment for the patient prior to admission or transfer.
-All Patients requiring transfer because the inpatient psychiatric unit does not have the capacity or capability will be transferred to another psychiatric facility via EMS or Security and Hospital personnel. No patient will be transferred via personal vehicle.

Review of hospital policy, Admission to 7W - Criteria and process" reviewed 05/2013, showed that each patient must be assessed, evaluated and given a diagnosis before he/she may be admitted to the 7 West BHU. The Emergency Physician and the 7 West Behavioral Health Unit (BHU) psychiatrist on call or the patient's personal psychiatrist will determine the appropriate course and give the order for admission. The policy described below showed the hospital had the capability to provide stabilizing treatment to patient # 1, who presented to the ED on 12/16/13 at 1:53 PM.


A. Inpatient admission criteria include (but are not limited to):
1. Threat to self- requiring 24-hour professional observation
a. Suicidal ideation or gesture within 24 hours prior to admission
b. Self- mutilation (actual or threatened) within 24 hours prior to
admission
c. Chronic and continuing self -injurious behavior that poses a significant
and/or immediate threat to life, limb, or bodily function.
2. Threat to others requiring 24-hour professional observation:
a. Assaultive behavior threatening others within 24 hours prior to
admission.
b. Significant verbal threat to the safety of others within 24 hours prior to
admission.
3. Command hallucinations directing harm to self or others where there is the
risk of the patient taking action on them.
4. Acutely disordered/bizarre behavior or psychomotor agitation that interferes
with the activities of daily living (ADLs) so that the patient cannot function at a
less intensive level of care during evaluation and treatment.
5. Cognitive impairment (disorientation or memory loss) due to an acute Axis I
disorder that endangers the welfare of the patient or others.
6. Patients with a dementia disorder who need evaluation or treatment of a
psychiatric co-morbidity e.g., risk of suicide, violence, severe depression)
warranting inpatient admission.
7. A mental disorder causing major disability in social, interpersonal,
occupational, and/or educational functioning that is leading to dangerous or
life-threatening functioning, and that can only be addressed in an acute
inpatient setting.
8. A mental disorder that causes an inability to maintain adequate nutrition or
self-care, for which family/community support cannot provide reliable,
essential care, so that the patient cannot function at a less intensive level of
care during evaluation and treatment.
9. Failure of outpatient psychiatric treatment so that the patient requires 24-hour
professional observation and care. Reasons for the failure of outpatient
treatment could include:
a. Increasing severity of psychiatric symptoms;
b. Noncompliance with medication regimen due to the severity of
psychiatric symptoms;
c. Inadequate clinical response to psychotropic medications;
d. Due to the severity of psychiatric symptoms, the patient is unable to
participate in an outpatient psychiatric treatment program.
10. Other conditions may be present:
a. A recent weight loss/gain refractory to aggressive outpatient or partial
hospitalization therapy;
b. Mental Disorder refractory to a thoroughly documented effort at
aggressive outpatient or partial hospitalization (e.g. recurrent
psychosis not responsive to outpatient treatment, severe depression.
Or failing to respond to (21) days of outpatient drug therapy;
c. Toxic effects of therapeutic psychotropic drugs;
d. Introduction of, withdrawal from or change in dose of
psychotherapeutic medication(s), in cases in which there is strong
reason to believe that potentially serious side effects are likely to
occur( e.g. due to high doses and/or co-concomitant cardiac disease
known to be sensitive to the drugs in question).

Review of the December 16, 2013 Daily Bed Management sheet for 7 West BHU showed there were 18 occupied beds out of 25, and one confirmed pending discharge and 3 potential discharges.

Review of a closed medical record showed Patient # 1 presented to the facility's emergency department (ED) by ambulance on December 16, 2013 at 1:53 PM. Documentation sent from the Nursing Home (NH) where patient # 1 resided included two affidavits to support admission for 96 hours. The affidavits showed patient # 1 had become hostile, assaulted nursing home staff, threatened to elope, would not redirect, and was "clearly a danger to himself and potentially other residents." At 2:00 PM the ED nurse documented patient # 1 stated he "is being manipulated at the NH." Further documentation revealed patient # 1's past medical history included Schizophrenia (chronic, severe, and disabling mental illness), Bi-polar disorder (a mental illness that causes shifts in mood, energy, and ability to function), Anxiety, and High Blood pressure. At 2:15 PM the ED physician examined patient # 1 and documented the patient had been involved in an altercation prior to arrival, that a family member was the patient's durable power of attorney (DPOA) who arranged commitment to long-term care for his schizoaffective personality disorder, that the patient seemed "somewhat tangential (irrelevant responses), and religiously preoccupied", but denied SI/HI (suicidal ideation, homicidal ideation), and that the patient had been discharged from the behavioral health unit on 7 West February 2013. At 2:32 PM the ED nurse documented a sitter was assigned to closely monitor patient # 1 after he attempted to leave the ED and that security was summoned to encourage the patient to remain in his room. Further documentation showedt the ED nurse administered to patient # 1 an intravenous dose of an anti-anxiety medication (Ativan). At 2:35 PM the Licensed Professional Counselor (LPC) interviewed patient # 1 and documented the patient was mildly paranoid with fair insight and judgment. The LPC documented conferring with the on call psychiatrist who determined the patient did not meet clinical criteria for inpatient psychiatric hospitalization. At 4:03 PM the ED nurse documented patient # 1 became increasingly agitated and hostile after being told he would be discharged back to the nursing home and that Patient # 1 screamed at staff and pulled out his intravenous (IV) catheter while verbally and physically assaulting ED staff. The ED nurse completed an affidavit to support admission for 96 hours. The affidavit documentation showed patient # 1 became upset and forcefully pushed his sitter into the corner of the room while screaming "get out of my face." At 3:55 PM patient # 1 received an injection of an antipsychotic medication (Geodon). At 5:54 PM the ED physician documented he spoke with the on call psychiatrist who requested patient # 1 be admitted to Hospital B. ED staff documented on the transfer form patient # 1's "Medical Condition: Diagnosis: [was] Agitation" and that the patient would be transported by ambulance to Hospital B. The space on the transfer form for "Support/Treatment during transfer" included a blank space for "Restraints - Type or Other." The medical record did not contain evidence that the hospital processed an involuntary commitment or stabilized patient # 1's psychiatric emergency medical condition within its capabilities or capacity and did not arrange admission to the psychiatric unit on 7 West. Review of patient # 1's prior 7 West medical record dated February 1 - 28, 2013 (and reviewed by the ED physician on 12/16/13) showed the patient had threatened to kill self and exhibited assaultive behavior towards staff early in his admission. Further documentation in the 7 West February 2013 medical record showed patient # 1 had a long history of psychiatric illness and had been hospitalized multiple times.

Review of the December 16, 2013 ambulance report showed patient # 1 left the ED at 7:29 PM and was seated in the ambulance with the seat belt fastened for transport to Hospital B. Further documentation showed the ambulance arrived at Hospital B at 7:33 PM and that an ambulance crew member observed patient # 1 walk out of the front door of Hospital B after refusing to fill out the intake form.

During a telephone interview on January 6, 2014 at 3:13 PM, emergency medical technician (EMT) X stated that dispatch sent them a "non-emergency transport" from Research Medical Center to Hospital B. He stated that the ED nurse did not tell them about the patient's prior elopement attempt and he did not remember being told the patient had pushed the ED tech (technician). He stated that he and his partner had walked the patient into Hospital B but his partner then left and went back to the ambulance. He stated that had they known of the elopement attempt and the violence in the ED, they both would have stayed with the patient.

During an interview on December 23, 2013 at 4:03 PM, the Director of Risk Management (Staff B) stated Research Medical Center does not have a policy which dictates how a patient was to be transported out of the ED with EMS personnel.

During a telephone interview on December 26, 2013 at 10:45 AM, nurse S at Hospital B stated she received report from ED nurse J and that the patient would be transported by ambulance to their hospital. She stated she was told the patient had been agitated at the NH where he lived and had thrown a medication cart. She stated she was told he became a little combative with staff, security had been called, and that the patient had been medicated and was now calm and cooperative. She stated she had not been told he tried to elope or that he had become physically abusive while in the ED.