HospitalInspections.org

Based on policy review, medical record review, and staff interview, the facility failed to follow their policies and procedures for care provided in the emergency department for one of 20 emergency department medical records reviewed (Patient #33). A total of 27,468 patients were seen in the emergency department in the last six months.

Findings include:

Review of the "Patient Safety Monitoring for Suicidal and Non-Suicidal" policy, effective 07/01/21, revealed assessment of a suicidal patient includes completion of the Columbia-Suicide Severity Rating Scale (C-SSRS) upon admission to the emergency department. The patient will be placed on suicide precautions and monitored accordingly based on the C-SSRS. The C-SSRS will determine if a one to one patient monitor, a continual visual sitter, or no monitor but just hourly rounding is needed.

Review of the medical record for Patient #33 revealed an arrival date of 01/19/24 at 9:28 AM to the emergency department. The triage note at 9:36 AM documented the patient was having suicidal thoughts but denied having a plan. The medical record lacked documentation of a C-SSRS or orders for patient monitoring. The medical record noted registration was completed at 10:06 AM and blood was drawn for ordered labs at 10:57 AM. At 12:05 PM, the patient was assigned a room in the emergency department. At 12:21 PM, the medical record noted the patient was not in the lobby. The medical record contained documentation the facility and facility grounds were searched without location of the patient. Since the patient reported suicidal thoughts, the local police were contacted to locate the patient and return him to the emergency department. The emergency department was notified on 01/19/24 at 9:14 PM, that the police were unable to locate the patient. The medical record contained documentation that the patient has been admitted to this facility for medical reasons twice since 01/19/24.

On 02/08/24 at 12:10 PM, Staff FF stated that on 01/19/24 they were busy and had eight to ten patients waiting in the lobby at this time for a room. They usually had security keep an eye on any psychiatric patients temporarily until a sitter could be obtained. Staff FF verified that no sitter was ordered, no suicide screening (C-SSRS) was completed, and there was no documentation of any need for monitoring in the medical record.

Based on record review and staff interview; the facility failed to ensure qualified medical personnel were determined in the bylaws or rules and regulations as qualified to administer a medical screening examination (A2406). The facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on facility policy review, review of facility medical staff bylaws and medical staff rules and regulations, and staff interview, the facility failed to ensure qualified medical personnel were determined in the bylaws or rules and regulations as qualified to administer a medical screening examination. The facility's emergency department saw 27,468 patients in the last six months.

Findings include:

Review of the facility's policy titled, "Responsibilities of Genesis Emergency Department in Emergency Cases (EMTALA)", effective 02/09/23, revealed a Medical Screening Examination (MSE) must be conducted by qualified medical personnel to determine whether or not an Emergency Medical Condition exists. The MSE must be conducted by an individual determined to be qualified by hospital by-laws, rules and regulations, or approved by the Board of Directors.

Review of the facility's Medical Staff Bylaws and Medical Staff Rules and Regulations lacked documentation to designate or define who were qualified medical personnel and who was designated to perform the MSE to determine the presence or absence of a medical emergency condition as referenced in the facility's EMTALA policy.

Interview with Staff D on 02/08/24 at 4:50 PM confirmed the Medical Staff Bylaws and Medical Staff Rules and Regulations failed to define or designate who the qualified medical personnel was and who could perform the MSE to determine the presence or absence of an emergency medical condition.

Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for three of three medical records of transferred patients reviewed (Patient #27, #28, and #29). A total of 20 emergency department medical records were reviewed. A total of 27,468 patients were seen and 544 patients were transferred to other facilities in the last six months.

Findings include:

Review of the policy titled, "Psychiatric Patients Awaiting Evaluation in the Emergency Department," effective 05/13/21, revealed a Writ is a legal document that may be signed by a physician, law enforcement officer, or mental health professional that permits a person to be held without their permission when it has been determined that the person is a threat to self or others.

1. Review of the medical record for Patient #27 revealed an arrival date of 11/05/23 at 8:43 PM to the emergency department. The medical record contained documentation the patient was suicidal and homicidal. The medical record progress notes documented that the patient had been placed on a Writ. The medical record contained documentation the patient was transferred to a psychiatric facility on 11/06/23 at 11:22 AM. The medical record lacked documentation of a Writ or a transfer document that listed the risks and benefits of the transfer signed by the physician.

2. Review of the medical record for Patient #28 revealed an arrival date of 09/03/23 at 3:30 AM to the emergency department. The medical record contained documentation the patient was transferred to a Level 1 Trauma facility by a Mobile Intensive Care Unit on 09/03/23 at 6:50 AM. The "Consent to Transfer to Another Facility" form was signed by the physician; however, the risks and benefits of transfer section was blank.

3. Review of the medical record for Patient #29 revealed an arrival date of 01/10/24 at 12:59 PM to the emergency department. The medical record contained documentation the patient had third degree burns to his right lower extremity. The medical record contained documentation the patient was transferred to a burn center on 01/10/24 at 3:12 PM. The medical record lacked documentation of a transfer document that listed the risks and benefits of the transfer signed by the physician.

On 02/08/24 at 10:45 AM, Staff FF verified the above findings in an interview.