HospitalInspections.org

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases] resulting in the potential for less than optimal outcomes for all patients seeking emergent care.

See Specific Tags:

A-2402 Failure to have conspicuous EMTALA signage in the patient waiting area
A-2407 Failure to treat and stabilize a patient prior to discharge
A-2409 Failure to provide proper transfer

Based on observation and interview, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs in waiting room areas were conspicuous and likely to be noticed by all individuals that visit the Emergency Department resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 3/27/2023 at 1018 during the initial tour of the Emergency Department (ED), the ambulance bay/receiving area was entered. Two EMTALA signs, approximately 12" x 12" were noted to be in the general area; however, neither was able to be easily visualized by a patient entering through the ambulance bay. The first one was located behind a pillar near the security desk to the right of the double doors leading to the waiting/triage area. The second was posted on a wall around the corner on the nearest wall to the ambulance bay, which could be read by individuals leaving the ED and exiting through the ambulance bay, or on their way to the waiting room.

Upon entering the waiting area, an EMTALA sign, approximately 12" x 12", was observed to the left of the double doors in the registration/waiting area leading to the ambulance entrance. The registration and triage area was a series of cubicles designed to ensure privacy for patients who were getting "mini-registration" and triaged; however, did not permit visualization of the EMTALA sign. Additionally, the sign could not be read from the waiting area which was to the right of the double doors leading to the ambulance bay.

Another EMTALA poster, approximately 12" x 12", was observed posted behind a pillar just to the right of the front desk and in the middle of four other larger and brightly colored posters.

An additional waiting area to the right of the front desk near the vending area was also toured and no EMTALA signage was found to be present.

On 3/27/2023 at 1030, Staff D was queried as to if she thought all patients would be able to read the EMTALA signs which were present to which she stated, "No." She was then queried as to if she was able to locate any signage in the waiting area near the vending machines to which she stated, "No. I don't see any."

Facility policy #2 ED 156 (COMP-RCC 5.16) titled "EMTALA - Emergency Medical Treatment and Labor Act" effective 7/15/2022 states, " Posting Signs 1. The Hospital must post conspicuously in the Dedicated Emergency Departments and all areas in which individuals routinely present for treatment of emergency medical conditions and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) signs in the format of the attached Attachments A and B that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions. 2. The Hospital must conspicuously post signs stating whether or not the Hospital participates in the Medicaid program. 3. All signs must be posted in all the major languages that are common to the population of the Hospitals service area."

Based on interview and record review, the facility failed to provide stabilizing treatment to 2 (#7, 21) of 3 petitioned patients, resulting in the potential for adverse outcomes, including death, to all patients with a petition for mental health who seek treatment in the Emergency Department (ED). Findings include:

Review of the medical record for Patient #7 on 3/28/2023 at 0935 revealed he was a 41-year-old male who presented to the Emergency Department (ED) on 10/25/2022 at 0752 via ambulance. He had been found by the local police department after family reported he was suicidal. Review of the electronic medical record (EMR) revealed a triage note dated 10/25/2022 at 0752 that Patient #7 had been petitioned (a legal document stating a person is in need of psychiatric evaluation) by the police officer.

ED Resident Physician documentation dated 10/25/2022 at 0833 revealed Patient #7 had taken 15 Ambien and 15 Xanax. Patient #7 stated he had constant abdominal pain and felt that no one was taking him seriously. He was tired of the pain, so took the medication. Physical examination revealed a soft, non-distended abdomen with some tenderness and guarding. The patient was placed on suicide and elopement precautions. Following lab testing and x-rays, no acute processes were found and Patient #7 was medically cleared for psychiatric review. No mention of a petition is made in the ED resident physician's evaluation or in the ED Attending Physician Staff X's documentation.

During an interview with ED Attending Physician Staff X on 3/29/2023 at 1026, he stated Patient #7 had come to the ED for a medical clearance and psychiatric evaluation after ingesting Ambien and Xanax. "We observed him, got labs - everything was okay. He was fully alert and awake. He was conversant with me ... I don't think he took as many of the medication as he said because he just wasn't that sleepy ..." Staff X stated he was unsure whether he was aware that Patient #7 had been petitioned at the time. He further stated communicating a patient was petitioned was part of his normal routine. "I did not indicate there was a petition in my note, which I would have done, so I don't think I knew about it at the time." When queried as to if he were aware the family of Patient #7 had called requesting admission, he stated he did not "believe nursing told me about the phone call."

Review of the Crisis Center Assessment completed by Psychiatrist Staff Y on 3/25/2022 at 1318 revealed Patient #7 had admitted to taking "3 Ambien and 2 Xanax because he was depressed... he says it was not a suicide attempt however he does admit he texted his mother he couldn't take it anymore. Says he has never had SI (suicidal ideation) in his life and feels fine now. Says he is not depressed... " In the associated symptoms, it listed mild depression. "Predisposing factors: h/o (history of) mental illness. Precipitating factors: Non-compliance with medication ... Recommended referral: Inpatient psychiatric unit ... Tolerance and Impulsivity: Frustration Tolerance: Fair. Impulsivity Level: Mild. Insight: Limited. Judgment: Limited ... Diagnosis: Depression NOS (not otherwise specified)." Patient #7 denied a history of suicide attempts. "Initial Tx (Treatment) Plan of Service/Level of Care Outpatient Treatment Program: Patient does not meet criteria for (Inpatient care, Higher levels of care)."

Psychiatrist Staff Y stated during interview on 3/30/2023 at 1104 he was approached by Patient #7 while he was in the ED evaluating another patient. Patient #7 told him it was a big mistake he was there and he did not need to be there. "I read through the chart and was skeptical that he took as much medication as the resident had reported due to the fact he was alert and oriented. It didn't seem like true information. I believed him. He was not overly sedated, and he had no past psychiatric history." After evaluation, Patient #7 was following him around the ED and stating he was ready to go. "Staff witnessed him making appointments and he appeared future oriented." When queried as to if he were aware the patient had been petitioned, Staff Y stated, "Looking back, the orders for consult did not mention a petition. It usually does. There was nothing in the ED resident or attending notes about a petition."
Psychiatrist Staff Y was then queried as to if he had known there was a petition if it would have changed the outcome to which he stated there would be an increased concern for a patient who had been petitioned as it showed there was someone else concerned for the patient. "It shows a lot better insight into the condition of the patient and there is a high admission rate for petitioned patients."

An interview was also conducted with Patient #7's primary nurse, Staff F on 3/29/2023 at 0947. She stated she had received a phone call from Patient #7's sister stating he was sick and needed help. The sister further stated this was not his first attempt at suicide and requested he be admitted to the hospital. "I told her, per protocol, he has to stay and be cleared by psych." When queried as to if she told the ED resident physician, ED attending physician, or the Psychiatrist about the phone call from the family, Staff F stated, "I don't know if I did at the time. It didn't feel important until he came in the next day and then I said something. He was petitioned and it was noted he was suicidal on the chart. I guess I thought the system would work."

During their respective interviews mentioned above, both ED Physician Staff X and ED Psychiatrist Staff Y stated it would not be their habit to review nursing documentation (triage note) and they would expect a phone call from the family stating the patient was suicidal to be verbally brought to their attention.

Further review of the medical record revealed Patient #7 was discharged home in fair condition with instructions to follow-up for outpatient treatment on 10/25/2022 at 1342 after spending 5 hours and 50 minutes in the ED.

Of note, a late entry for suicide screening was found in the medical record and was performed on 10/25/2022 at 1347 but not entered into the record until 10/26/2022 at 1351. To the question "Have you wished you were dead or wished you could go to sleep and not wake up?" the response was "Lifetime, yes." All other questions regarding actual thoughts of suicide, developing a plan for suicide, thoughts and intentions to act on thoughts of suicide, working out the details of suicide with the intention to carry them out, and asking if the patient has ever done anything, started to do anything, or prepared to do anything to end his life were all answered "no."

Review of the medical record for Patient #7 dated 10/26/2022 revealed he arrived to the facility via ambulance at 1026 with a chief complaint of drowning. The Emergency Treatment Note dated 10/26/2022 at 1544 stated, "Patient reportedly had a suicide attempt yesterday. Today, he reportedly informed family that he was planning to jump in the river and drown himself. Family called 911 who responded to the call. Patient was found in the Detroit River ... "

ED Attending Physician Staff AA stated during interview on 3/29/2023 at 1040 that on Patient #7's arrival to the facility a urinary catheter and chest tubes were placed to allow warmed fluid lavage. Additionally a heated air blanket and a heated external fluid pad device were used to help warm the patient. Eventually, resuscitative efforts were terminated and the patient was pronounced on 10/26/2022 at 1312.

A Root Cause Analysis (RCA) was conducted by the facility and was started on 10/26/2022. The process included a summary of events, a summary of interviews, and an action plan. Items in the action plan were to be implemented by 12/9/2022. The RCA concluded there was no formalized process for knowing if a patient had been petitioned, and, if the psychiatrist had been aware of the petition, Patient #7 may have met inpatient criteria.

On 3/29/2023 at 0945 a tour of the Emergency Department was conducted to obtain interviews with staff concerning RCA interventions that were to be implemented for patients received with petitions for mental health treatment. The ED was very busy at the time of the tour. Staff U, an ED registered nurse, was queried if he was aware of the pathway or schematic tool that was to be used with a petitioned patient. Staff U was located in section #3. Staff U stated, "No ...I'm not sure what you are referring to." Staff U was then asked if there was a pop up on his computer screen to alert him that a patient was petitioned. Staff U responded, "No. I'm unaware of a pop up on the computer screen." At the time of the interview a patient (pt. #37) was currently in section #3 under a petition.

On 3/29/2023 at 1005 an interview was conducted with staff I, the Chief physician of the ED. Staff I was queried if he was aware of a pathway or schematic tool to be used with patients presenting to the ED with a petition for mental health treatment. Staff I was unaware of the tool. Staff I was queried if he was aware of any changes in identifying a patient with the petition of mental health treatment. Staff I stated he was new to the facility as of January and "the process has never changed." Staff I was also asked if the computer system for the electronic medical record provided an alert to let physicians know that a patient was present under a petition for mental health treatment. Staff I stated, "I am unaware of anything related to the computer system that alerts physicians of a petition."

On 3/29/2023 at 1015 an interview was conducted with staff V, an ED registered nurse. Staff V was queried if she was aware of any alerts for a petitioned patient in the ED or if she had received any education about how to identify a petitioned patient in the last 4 months. Staff V stated she was not aware of any changes. Staff V was then asked if a computer alert is provided to staff to alert staff of a petitioned patient. Staff V stated, "No ...there is nothing like that that I'm aware of."

On 3/29/2023 at 1030 an interview was conducted with the interim ED RN manager, staff D. Staff D was asked if she could provide the pathway or schematic tool for how a patient with a petition for mental health treatment was to be followed. Staff D stated the tool was located at the triage desk. Staff D was followed to the triage desk. Staff D looked at the documents posted on the desk for staff to use. Staff D stated she was unable to find the document posted. Staff D then shuffled through a stack of papers and was able to locate the tool for a patient with petition for mental health treatment. Staff D was then queried if staff were trained on the tool. Staff D stated, "The ED educator left abruptly a week ago ...I do not know if she ever trained anyone. I will look in her office to see if I can locate any education materials." Staff D later in the day followed up to state no education could be provided.

Chief Nursing Officer Staff C admitted on 3/30/2023 at 0912 the RCA had not been implemented. "People know what a petition process is but can't speak concisely about it... We fall short in letting the provider know the patient is petitioned. From the provider stand-point, they look in a certain spot and the information doesn't translate to where they are getting their information... We recognize the physicians have an obligation to know the medical record and to know about petitions... We've learned we are not communicating well as a team."

On 3/30/2023 at 0930 a request was made for the RCA policy to Quality Director Staff R. Staff R stated, "We do have a policy, but it is not what you think. The policy is that we do them. It does not speak to the process." The policy was not provided prior to exit of survey.

Review of the medical record for Patient #21 revealed he was a 55-year-old male who presented to the ED 12/29/2022 at 0527 with a chief complaint that he wanted to "see a psychiatrist for mental health." The ED Treatment Note dated 12/29/2022 at 0553, the patient refused to elaborate on why he wanted to be seen. Patient #21 had a known history of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). He was medically cleared for psychiatric evaluation in the Crisis Center.

Nursing documentation dated 12/29/2022 at 0549 revealed the patient was complaining of auditory hallucinations. and stated he needed housing. He denied hearing verbal commands to commit suicide or homicide and hygiene was described as "poor." The Columbia suicide scale (a tool used to determine if the patient is suicidal) was negative.

On 12/29/2022 at 0712, a Crisis Center Assessment by an attending physician revealed reference to a report. It does not indicate when the report was written and it is difficult to discern what portion is from the report and what was current assessment. It states the patient was depressed and using drugs. The chief complaint was "I want to kill myself." Documentation revealed he presented with depression and poor impulse control. The plan was to observe the patient overnight, monitor for manic, hypomanic, and psychotic symptoms, monitor for suicidal and homicidal ideation, medicate as needed, and a disposition would be determined based on symptoms. The assessment portion of the document stated he was depressed but had no suicidal ideation, then reiterated, "not actively suicidal." The documentation showed the need for a 1:1 constant observer and a past history of suicidal ideation with plan. It was noted Patient #21 had "access to method of choice." Further down the document was a question, "Is the patient suicidal now?" The response is, "Yes, yes." Duration of the suicidal ideation is listed as "chronic." The treatment plan was to observe behavior for a 23-hour hold.

Another Crisis Center Assessment was conducted 12/29/2022 at 0831 (1 hour, 19 minutes later) by a different attending physician. He noted Patient #21 was chronically mentally ill. He wrote, "Patient admits to multiple threats of self-injury or suicide often accompanied by non-lethal, low-risk, high rescue gestures at self-harm ... In the past and now, it is my opinion that this patient was feigning or grossly exaggerating their risk for self-injury and/or suicide to gain entry into a psychiatric hospital as a secondary gain ..." The recommendation was for outpatient treatment. Patient #21 was discharged at 1240.

Patient #21 was brought back to the ED on 12/30/2022 at 2221 by the local police department after he was hit in the head during a fight at a local liquor store. He denied loss of consciousness. Following medical clearance, he was diagnosed with an "acute assault, facial contusion." And was discharged at 0225.

Patient #21 was brought back to the ED again on 12/31/2022 at 0332 (1 hour and 7 minutes after being discharged after the assault) being petitioned by his family for increasing violence and aggression and not taking his medications. Boxes on the petition were marked indicating as a result of mental illness, the patient could be "reasonably be expected within the near future to intentionally or unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant threats that are substantially supportive of this expectation ... is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs ... judgment is so impaired by that mental illness and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition and presents a substantial risk of significant physical or mental harm to the individual or others."

Nursing documentation (12/31/2022 at 0402 ED Triage Assessment) as well as ED Physician documentation (Emergency Treatment Note dated 12/31/2022 at 0400) clearly revealed the presence of a petition for Patient #21.

A Crisis Center Assessment dated 12/31/2022 at 0655 stated ED Psychiatrist Staff Z had reviewed nursing and ED physician documentation. His assessment was that Patient #21 was "functioning at baseline", "not overtly psychotic", had "treatment established", and there was "no indication for psychiatric hospitalization." "Precipitating factors for this episode: Non-compliance with medications ... Use of drugs and alcohol ..." On exam, patient symptoms included: delusions, hallucinations, poverty of speech (lack of conversation; can be indicative of serious mental illness, brain injury or dementia), insomnia, not eating, not drinking fluids, poor hygiene, labile effect (sic; rapid, often exaggerated changes in mood where strong emotions or feelings occur), impulsivity ... Severity of the symptoms: Severe ...frequency of ASSOCIATED symptoms: Daily." Impulsivity level was documented as "Moderate." Behaviors were described as "shouting, cursing, insulting temper, outbursts, threatening violence toward others. Aggression toward property: Slam (sic) doors. Aggression towards others: Makes threatening gestures. Patient's violence is: Chronic substance related Mental illness related ... Diagnosis: Schizophrenia." The assessment indicated Patient #21 was "psychiatrically stable" and was able to be discharged home with outpatient treatment recommended. There was no mention in the Crisis Center Assessment that Patient #21 had been petitioned.

During an interview with ED Psychiatrist Staff Z on 3/29/2023 at 1021, he stated petitioned patients had a higher tendency to be admitted for higher care because someone thought they needed higher care. The psychiatrist would have to carefully evaluate the patient, review the petition, and decide if a higher level of care was needed.

Review of facility policy #PMH 156 titled "Inpatient Unit Admission, Continued Stay and Discharge Criteria (Adult)" effective 9/4/20 states, "The specific requirements for severity of need and intensity and quality of service for admission is based on the judgement of the screening clinician from the psychiatrist/resident that the patient is displaying signs and symptoms of a serious psychiatric disorder, demonstrating related functional impairments, manifesting a level of clinical risk that either individually or collectives are of such severity that treatment in a less restrictive environment would not be safe or ineffective and the patient has the psychological and cognitive capacity to respond to the inpatient program. It is expected that active treatment will reasonable result in improvement in the patient's condition... Admission criteria... 1. Must have a primary mental illness... that significantly impairs judgement, behavior, capacity to recognize reality, or ability to cope with ordinary demands of life. 2. Must demonstrate acute symptoms ad behaviors indicative of the need for 24-hours continuous monitoring and assessment. 3. Can reasonably be expected within the near future, to intentionally or unintentionally cause significant physical harm to self or others. 4. As a result of mental illness, are unable to attend to those basic physical needs (such as food, clothing, and shelter) that must be attended to in order to avoid serious harm in the near future. 5. As a result of mental illness, are unable to understand the need for treatment, and continued behavior can reasonably be expected to result in significant physical harm to self or others..."

Based on interview and document review, the facility failed to explain and document the risk and/or benefits of transfer for 1 (#42) of 1 patients reviewed for transfer prior to transferring the patient, resulting in the potential for unsatisfactory outcomes. Findings include:

On 3/28/2023 at 1600, review of the facility Emergency Department (ED) Discharge Log from 9/1/2022-present revealed there was only one transfer, Patient #42, during that timeframe that transferred to another facility.

Review of the medical record for Patient #42 on 3/29/2023 at 0945 revealed she was a 31-year-old female that presented to the ED 3/11/2023 at 0302 with a chief complaint of severe lower abdominal pain and back pain. Nursing documentation dated 3/11/2023 at 0303 revealed she was in "moderate distress, 10/10 pain, sreaming (sic), states she is labor. Crowning of fetal head is noted."

The ED Treatment Note dated 3/11/2023 at 0302 revealed Patient #42 had been having lower abdominal cramping for most of the day. "Patient believes she is approximately 40 weeks pregnant... the patient appears extremely uncomfortable... Fetal head was delivered... Subsequent delivery of the anterior and posterior shoulders. Umbilical cord was clamped and cut. At this juncture gynecology has arrived... Gynecology transported the patient to (name of nearby sister hospital) at 0325." The disposition states, "Patient is transferred to (name of nearby sister hospital) in guarded condition (acute illness with questionable outlook; the person formulating the condition does not have enough information to know or to foretell what the outcome may be.)"

Review of the GYN consult note dated 3/11/2023 at 0341 revealed a birth alert was called in the ED. Patient #42 had stated her membranes had ruptured at approximately 0200. Upon the arrival to the ED, she felt the urge to push. The baby was delivered with no concerns on 3/11/2023 at 0305.

Per nursing notes dated 3/11/2023 at 0325, the patient and her newborn daughter were transferred to a nearby sister hospital to the Labor and Delivery unit "via stretcher and incubator respectively."

During review of the medical record on 3/29/2023 at 0945, a request was made to view the EMTALA transfer form. The form could not be found in the medical record. No documentation was present in the medical record to indicate the risks and/or benefits of transfer, who was accepting the patient at the receiving facility, how the patient was to be transferred, what equipment would be needed for transfer, and no permission given by the patient for the transfer.

Chief of ED Staff I stated the "transfer paperwork" was "absolutely necessary." He stated all physicians knew it was an expectation and was required.

Facility policy #2 ED 156 (COMP-RCC 5.16) titled "EMTALA - Emergency Medical Treatment and Labor Act" effective 7/15/2022 states, "When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures. a) The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual's health and, in the case of a woman who is having contractions, the health of the unborn child. b) A representative of the receiving facility must confirm that: (1) The receiving facility has available space and qualified personnel to treat the individual and (2) The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment. c) The Hospital must sent to the receiving facility copies of all pertinent medical records available at the time of transfer... d) The transfer must be affected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer. 3. Patient Refusal of Transfer. If the Hospital offers an appropriate transfer and informs the individual or the person acting on the individual's behalf of the risks and benefits to the individual of the transfer, but the individual or the person acting on the individual's behalf does not consent to the transfer, the Hospital must take all reasonable steps to have the individual or person acting on the individual's behalf acknowledge such refusal in writing. If the individual refuses to acknowledge in writing, the medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual."