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Based on document review, and staff interview, the facility failed to ensure that notification was made to LRCA (Local Rabies Control Authority) following patients presenting with animal bites to the emergency department in 5 of 5 medical records reviewed. This was not in compliance with facility policy.

Findings included:

Facility policy " Care of The Patient Suspected Of Exposure To Rabies " stated, in part,

"C. San Antonio Metropolitan Health District is notified of the exposure or possible exposure. Animal Bite Report ( (NURS-ED-25A) is completed and a copy of report is to be faxed to Metro Health district nurse, (210) 207-2839, and Animal Care Services, (210) 207 6678,at time of visit. The original copy of the report is retained as part of the permanent ED record. A prescription for the remainder of the series should be faxed to the Metropolitan Health district nurse at (210) 207-2839 by the provider that will administer the vaccine. "

A review of medical records for patient #7, #8, #19, #20, and #21 during the investigation was missing documentation in the emergency medical record that notification was made to the proper authorities as per facility policy regarding animal bites.

In an interview on 1.30.2023 at 4:00 pm with Staff #2 who is the CNO verified that there was no existing paper log or other documentation stating notification had been made in 5 of 5 emergency room records reviewed for animal bites.

Based on review of facility policy and patient records, the facility failed to perform and document an appropriate medical screening examination (MSE), to include a full psychiatric evaluation by qualified medical personnel for patients experiencing a psychiatric emergency, to determine if the patient was stable or had an emergency medical condition in 1 out of 20 records reviewed (Patient 1).


Findings included:

A review of the facility policy titled "Triage, Registration and Treatment," document number RM-EMTALA-041, stated in part,
"...C. Medical Screening Examination
1. An MSE will be provided by Qualified Medical Personnel to any individual who comes to the Dedicated Emergency Department. The MSE will be non-discriminatory and must be the same MSE the Baptist Health System ("Hospital") would provide to any individual coming to the Dedicated Emergency Department with those signs and symptoms, regardless of ability to pay.
2. The MSE will be performed by a physician or other Qualified Medical Personnel. The examination should be specific to the patient ' s complaint and presenting symptoms. The MSE may represent a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures.
3. Qualified Medical Personnel may contact the individual's physician at any time to seek advice regarding medical history and needs that may be relevant to the medical treatment and screening of the individual, as long as this consultation does not inappropriately delay necessary services.
4. In the event that Baptist Health System ("Hospital") does not have the capability or Capacity to stabilize the Emergency Medical Condition identified by the MSE, the Qualified Medical Personnel will coordinate with the Nursing Supervisor, Emergency Department Director or their designee(s) to identify a facility capable of treating the patient as outlined in Paragraph E(3) below.
5. Monitoring and care within the Baptist Health System ("Hospital") capability must continue until the individual is stabilized or appropriately admitted or transferred. The physician or other Qualified Medical Personnel will document the MSE, and ongoing patient assessment in the medical record...

...E. Individuals Who Have an Emergency Medical Condition
If the Qualified Medical Personnel performing the MSE determines the individual has an emergency medical condition, Baptist Health System ("Hospital") must:
1. Provide treatment within the capability and Capacity of the staff and facilities available which is necessary to stabilize the individual, until the Emergency Medical Condition has been stabilized; or
2. Admit the individual to stabilize and the Emergency Medical Condition; or
3. Arrange to transfer the individual to another medical facility if stabilization of the individual is beyond the capabilities or Capacity of Baptist Health System ("Hospital").

B. Based on a review of the document titled "Clinical Diagnosis" on page 32 of 83 of the medical record for Patient 1, Staff 11, the Attending Provider, identified the patient was:
At risk for elopement, Priority 1, Status: Active
Overdose, Priority 3, Status: Active
Psychiatric problem, Type: Reason for Visit, Status: Active
Suicidal behavior with attempted self-injury, Priority 2, Status: Active

A review of Patient #1s medical record, page 33 of 83, under "Emergency/Urgent Care", Staff 11, the Attending Provider, documented the following:
"Chief Complaint: Pt arrives to ED with girlfriend with complaints of suicidal attempt by taking multiple unknown pills such as molly and meth pt took pills this afternoon, admits to AH and VH, unsure about HI per pt."

Under "HISTORY OF PRESENT ILLNESS", Staff #11, the Attending Provider, documented the following:
"Pt states that he took 'all the drugs'. His family member states that he was last normal about 1045. He borrowed her car and returned it at 1645 very intoxicated. She states that he had a bag of 'all the illegal drugs' and he ate it. He states that he was trying to kill himself. He has attempted SI in the past."

On page 34 of 83, under "MEDICAL DECISION MAKING", Staff #11, the Attending Provider, documented the following:
"MEDICAL DECISION MAKING:
He was initially on a voluntary admission and was cooperative. He decided after a while that he no longer wanted to be admitted and got up and walked out. He said if anyone tried to stop him, he would hit them. I am very concerned about this individual as he admitted to me that he wanted to kill himself and admitted to consuming an unknown amount of unknown 'illegal' substances. At this time, he is not cleared from a medical standpoint nor is he psychiatrically stable, we called SAPD who contacted him in the parking lot. SAPD eventually decided to allow him to go, and the patient never returned."

Based on a review of the patient's medical record, the facility did not complete a full MSE, as there was no evidence of a psychiatric evaluation conducted by qualified medical personnel. There was no documentation that the facility placed the patient on a one-to-one, despite auditory and visual hallucinations and persistent suicidal ideations after the patient stated he had taken multiple unknown pills. Additionally, Staff 11, the Attending Provider, identified that the patient was not psychiatrically stable.


Key:
PT - patient
ED - Emergency Department
AH - auditory hallucinations
VH - visual hallucinations
HI - homicidal ideation
SI - suicidal ideation
SAPD - San Antonio Police Department