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22489

Based on findings at A2405, A2406 and A2409, the facility failed to ensure compliance with C.F.R. (Code of Federal Regulations) 489.20 and 489.24.

Based on document review, interview, and record review, the facility failed to ensure a central log was maintained to allow tracking of each patient seeking assistance, whether the client or the facility refused treatment and the disposition of the patient; whether they were transferred, admitted and treated, stabilized and transferred or discharged for 6 of 6 months (Patient #7).

Findings include:

The facility policy titled EMTALA (Emergency Medical Treatment and Labor Act) Procedure for L2K (Legal 2000 Nevada Process for Civil Commitment) Patients at RNOPC (Rawson-Neal Outpatient Clinic) effective September 9, 2013 documented:
- "Purpose: To insure that a procedure is in place that will allow Rawson Neal Outpatient Clinic (RNOC) to remain in compliance with requirements set forth in the Emergency Treatment and Active Labor Act (EMTALA). It shall be the policy of the RNOC to provide an appropriate medical screening to all patients who present to the clinic for services, regardless of ability to pay, in order to assess whether an individual is experiencing an emergency medical condition. If the RNOC is unable to provide stabilizing treatment, the client will be transferred to the Rawson Neal Inpatient facility or to another hospital as appropriate."

The Outpatient Clinic (OP) logs for the months of June 2013 through November 2013 were reviewed. Interviews with the Psychiatric Nurse (PN) in the OP clinic and the Director of OP Services revealed the logs were created when a patient walked into the OP clinic for services. The patient completed the intake form, if they were a new admission. If they were a current patient, they would sign in at the desk and the clerk would pull up the previous information available for the patient.

On 11/7/13 at 4:00 PM, the PN House Supervisor revealed when a patient showed up at the facility after hours, which referred to after the OP Clinic hours, there was no log maintained. The PN verbalized when a patient presented to the hospital, the security guard would let the house supervisor know. The house supervisor would come to the entrance of the facility and do an assessment of the patient. Based on this assessment, if the patient was determined to be stable and safe, the patient would be sent home. If the PN determined the patient would need additional services, the PN called 911 emergency and had the patient transferred to an acute care facility.

The PN indicated she did not document the assessment that was performed and did not document the name of the patient presenting to the facility. The PN indicated the security guard documented the name of the patient presenting to the facility. The PN confirmed there was no log of all patients who presented after hours.

The PN indicated there may be 2-3 persons per week or 5-6 a month who present to the facility after hours.

On 11/7/13 at 4:10 PM,the security guard (SG) explained when a person presented to the facility and indicated they needed help or appeared in distress, the security guard would notify the house supervisor. The security guard indicated he would open the door and let the person in the facility and wait with the patient while the house supervisor came to see the patient.

The SG verbalized he would wait with the person and house supervisor. If the house supervisor determined the person was in crisis and needed further treatment, 911 emergency would be called and the person transferred to another hospital.

The SG added he documented the name of the individuals who presented to the facility after hours on the SG's daily journal. When there was a serious situation, such as a person in crisis who was transferred out to another facility, he would complete an report and submit it along with the daily security log.

The security logs for August 2013 through November 2013 were reviewed.

The SG Daily Journal and Operations Log dated 9/12/13 at 21:30 (9:30 PM) documented:
- "Lady showed up at (name of facility) claiming she needed help. AMR (American Medical Response) was called and took her to (Name) Hospital. More detail in (report) located in completed (report) folder."

There was no documentation of the patient's name who presented to the facility. There was no documented evidence of an assessment by any medical personnel, nurse or physician.

The SG Daily Journal and Operations Log dated 9/19/13 at 17:10 (5:10 PM) documented:
- "Lady came and wanted to be admitted into (name of facility). Advised her they needed to go to ER (Emergency Room) due to (name of facility) being closed."

There was no documentation of the name of the person who presented to the facility. There was no documented evidence of an assessment by any medical personnel, nurse or physician.

The SG daily log dated 10/1/13 at 1909 (7:09 PM) documented:
- " WFA (white female adult) came to lobby doors and advised she was supposed to be admitted tonight. (Staff Name) was contacted and took over."

There was no documentation of the name of the person who presented to the facility, either on the SG log, the log in the OP clinic, or Inpatient admissions.

On 11/12/13 at 3:00 PM, the Hospital Administrator (Adm) indicated there was no policy in place regarding how to handle after hours emergencies for people who show up at the facility when the clinic was closed and the doors locked.

The Adm verbalized when someone showed up requesting services after the clinic was closed, there was no requirement for the nurse to do an assessment. If there was a person needing immediate assistance, 911 emergency should called. There was no log maintained of people who presented to the facility after hours. If 911 emergency was called and there was a determination the patient was a legal 2000, there was no requirement for the nurse to complete a transfer form, as the person was not an admission to the facility.

The Adm added, the determination as to which the facility the patient was referred to was totally the decision of the EMS (Emergency Medical Staff). There was no communication between the staff at the facility and the receiving facility.



22489

Patient #7

Patient #7 and a case worker initially presented to the facility on 8/17/13 when the out-patient clinic was closed. The patient and case worker arrived by car from California. A Legal 2000 for poor insight, poor judgement, no social support and unable to care for self was initiated by the house supervisor. AN ambulance transferred the patient toan acute care hospital on 8/17/13. The patient was admitted to the acute care hospital from 8/17/13 to 8/20/13, with diagnosis of psychotic disorder.

From 11/7/13 to 11/8/13 several staff members were interviewed regarding Patient #7 presenting on the facility grounds on 8/17/13. There were no staff members who recalled the incident. There was no documented evidence a log was completed for patients requiring emergency medical treatment after the out-patient clinic was closed for the day.

On 11/8/13 in the afternoon, it was identified which Registered Nurse (RN) house supervisor was working at the time of Patient #7's incident. The RN house supervisor recalled the incident that occurred on 8/17/13 with Patient #7. The RN house supervisor indicated the patient could not be admitted to the facility since the out-patient clinic was closed. The RN house supervisor confirmed the incident and assessment was not documented. The security guard daily log had no documented evidence on the incident. The RN house supervisor indicated there was no policy regarding handling of patients who show up to the facility when the out-patient clinic was closed.

Complaint NV00037375





20127

Based on document review and interview, the facility failed to ensure that all patient who presented to the facility with possible psychiatric emergencies received consistent care including screening, stabilization, admission and/or transfer.

Findings include:

The facility opened an Out-Patient Clinic connected to the Psychiatric Observation Unit (POU) on 07/16/13. The out-patient clinic hours were 8:00 AM to 5:00 PM Monday and Saturday, 8:00 AM to 9:00 PM Tuesday through Friday and closed on Sunday. The out-patient clinic received patients by appointment and walk-ins. The patient's scheduled for appointments were recent discharged patients from the facility's inpatient untied. The out-patient clinic staff indicated 90% of the patients senn in the clinic were walk-in patients with no scheduled appointments. Three random dates were chosen from the out-patient clinic schedule from 8/12/13 through 11/12/13. One-third of the walk-in patients seen the the out-patient clinic had a psychiatric emergency medical condition. Those patients who were placed on a Legal 2000 hold were either admitted to the facility (if a bed was available) or transferred to an acute care facility for further evaluation.

The facillity's expectation was to have the out-patient clinic be open 24 hours a day seeing a majority of paitents as walk-ins with unscheduled appointments.

On 11/7/13 at 4:00 PM, the Psychiatric Nurse (PN) House Supervisor revealed when a patient showed up at the facility after hours, which referred to after the OP Clinic hours, the house supervisor would come to the entrance of the facility and do an assessment of the patient. Based on this assessment, if the patient was determined to be stable and safe, the patient would be sent home. If the PN determined the patient would need additional services, the PN called 911 emergency and had the patient transferred to an acute care facility.

The PN indicated she did not document the assessment that was performed and did not document the name of the patient presenting to the facility. The PN indicated the security guard documented the name of the patient presenting to the facility. The PN confirmed there was no log of all patients who presented after hours.

The PN revealed there may be 2-3 persons per week or 5-6 a month who present to the facility after hours.

On 11/7/13 at 4:10 PM, the security guard (SG) verbalized he documented the name of the individuals who presented to the facility after hours on the SG's daily journal. When there was a serious situation, such as a person in crisis who was transferred out to another facility, he would complete an report and submit it along with the daily security log.

The security logs for August 2013 through November 2013 were reviewed.

The SG Daily Journal and Operations Log dated 9/12/13 at 21:30 (9:30 PM) documented:
- "Lady showed up at (name of facility) claiming she needed help. AMR (American Medical Response) was called and took her to (name) hospital. More detail in (report) located in completed (report) folder."

There was no documentation of the patient's name who presented to the facility. There was no documented evidence of an assessment by any medical personnel, nurse or physician.

The SG Daily Journal and Operations Log dated 9/19/13 at 17:10 (5:10 PM) documented:
- "Lady came and wanted to be admitted into (name of facility). Advised her they needed to go to ER (Emergency Room) due to (name of facility) being closed."

There was no documentation of the name of the person who presented to the facility. There was no documented evidence an assessment was completed by any medical personnel, nurse or physician.

The facility policy titled Walk-in/Call-in Screening effective date 10/12 documented:
-" IV. Procedure:
- A. At no time shall a non-clinical staff member attempt to determine whether or not the person should be seen.
- B. At no time shall a non-clinical staff member send the person in an emergency or crisis away without being evaluated by a clinician."

On 11/12/13 at 3:00 PM, the Hospital Administrator (Adm) indicated there was no policy in place regarding how to handle after hours emergencies for people who show up at the facility when the clinic was closed and the doors locked.

The Adm verbalized when someone showed up requesting services after the clinic was closed, there was no requirement for the nurse to do an assessment. If there was a person needing immediate assistance, 911 emergency should called. There was no log maintained of people who presented to the facility after hours.




29140

Based on record review and staff interview the facility failed to ensure transfers were screened and carried out following regulatory requirements as required for 5 of 49 sampled patients (Patient #3, Patient #18, Patient #35, Patient #39, and Patient #7).

Findings include:

Patient #3

Patient #3 presented to the Outpatient (OP) Clinic on 10/7/13 with complaints of hearing voices telling her to go naked, and everyone was threatening her with knives.

Patient #3's skilled nurse's notes from the clinic documented Patient #3 had a previous admission at the facility with an incidence of assault.

During the nurse assessment, Patient #3 became violent and started to assault the nurse.

Patient #3 was placed on a Legal hold. Since there were no beds available in the facility, 911 emergency was called for transfer to another facility.

Patient #3's COBRA (Consolidated Omnibus Reconciliation Act) transfer form documented:
- Receiving Facility - Per Routine
- Receiving Physician - Blank
- Person Accepting - Blank
- Verbal Report Given - Blank
- Phone - Blank

Patient #3's medical record included a Legal 2000 form which indicated the patient was extremely agitated and assaulted a staff member.

There was no documented evidence of any medical record information sent to the receiving facility. There was no documented evidence a verbal report was given to the receiving facility.

Patient #18

Patient #18 presented to the Outpatient Clinic on 10/8/13 with complaints of being depressed and suicidal thoughts. The patient was evaluated by the psychiatrist and placed on a Legal 2000. The patient was transferred to another hospital for medical clearance.

Patient #18's COBRA (Consolidated Omnibus Reconciliation Act) transfer form documented:
- Receiving Facility - Per Routine
- Receiving Physician - Blank
- Person Accepting - Blank
- Verbal Report Given - Blank
- Phone - Blank

Patient #18's medical record included a Legal 2000 form which indicated the patient was depressed and increased risk for self harm.

There was no documented evidence of any medical record information sent to the receiving facility. There was no documented evidence a verbal report was given to the receiving facility.

Patient #35

Patient #35 presented to the Outpatient Clinic on 11/7/13 with complaints of active hallucinations. The patient was seen by a nurse and a psychiatrist.

Based on the psychiatric assessment, Patient #35 was placed on a Legal 2000 and transferred to (Name) Hospital by AMR (American Medical Response) ambulance for medical clearance and evaluation, as per the nurse's notes.

As per the nurse's note, a copy of the Legal 2000 form was sent with the patient. The form documented the patient was psychotic and could not care for self.

There was no documented evidence a COBRA (Consolidated Ominbus Reconciliationc Act) transfer form was completed. There was no documented evidence a report was provided to the receiving facility. There was no documented evidence copies of any additional medical record information was sent with the patient including the most recent vital signs.

Patient #39

Patient #39 presented to the Outpatient Clinic on 10/21/13 with complaints of suicidal ideations. The patient was hearing voices to hurt himself. The patient was assessed by the nurse and psychiatrist.

Based on the psychiatric assessment, Patient #39 was placed on a Legal 2000 and transferred to (Name) Hospital by ambulance for medical clearance and evaluation, as per the nurse's notes. The nurse's notes indicated a report was given to a nurse and physician at the receiving hospital.

There was no documented evidence a COBRA transfer form was completed. There was no documented evidence copies of the medical record including the assessments by the nurse and psychiatrist were sent with the patient.

On 11/12/13 at 3:00 PM, the Hospital Administrator (Adm) verbalized when someone showed up requesting services after the clinic was closed, there was no requirement for the nurse to do an assessment. If there was a person needing immediate assistance, 911 emergency should called. There was no log maintained of people who presented to the facility after hours. If 911 was called and there was a determination the patient was a legal 2000, there was no requirement for the nurse to complete a transfer form, as the person was not an admission to the facility.

The Adm added, the determination as to which the facility the patient was referred to was totally the decision of the EMS (Emergency Medical Staff). There was no communication between the staff at facility and the receiving facility.

The facility policy titled Interhospital Patient Transfers and COBRA Compliance, review date 5/13 documented:
- A. The Patient Transport Form is to be used anytime a patient from SNAMHS is transferred to another facility including, acute care medical facility for inpatient or emergency department care....
- 1. c. Enter reason for transfer and name of receiving facility.
- d. Enter the name of the receiving physician and name of the person authorized to accept the patient...
- e. Enter the name of the person receiving your verbal report and the phone number at which this person can be reached."





22489

Patient #7

Patient #7 and a case worker initially presented to the facility on 8/17/13 when the out-patient clinic and hospital lobby were closed. The patient and the case worker arrived by car from California. A Legal 2000 was initiated by the house supervisor for poor insight, poor judgement, no social support and unable to care for self. The patient was transferred to an acute care hospital on 8/17/13. The patient was admitted to the acute care hospital from 8/17/13 to 8/20/13, with diagnosis of psychotic disorder. The patient was transferred back to the facility on 8/20/13.

The acute care hospital Psychiatric consultation dated 8/18/13, documented:

"...History Of Present Illness: This is a psychiatry evaluation for a 26 year-old female with unknown past psychiatric history presenting to the hospital on legal 2000 stating that she is unable to care for herself. The patient states that she was essentially dumped here by her case manager yesterday. Is not able to state any reason why she was essentially dumped here by someone. She is very primitively self focused on discharge throughout the interview. She appears very, very guarded and give conflicting information throughout the interview. She does present extremely flat and guarded with very concrete thought process. She states that she has been taking her medications although she states that she takes medications for headaches. She states initially that she has never seen a psychiatrist in the past. However, upon learning that she is not leaving the hospital immediately today she does eventually open up that she has seen a psychiatrist in California just before coming to the hospital here. She states "I have been locked up for 7 months". She persist that she wants to leave the hospital, eventually she states that she wants to leave the hospital so she can "get a beer". She does state that she is taking her medications although she cannot name them off the top of her head. She states that she has been living in a shelter. She states that she has several family and friends in town. However again, she is getting very conflictual information throughout the interview. She denies actual psychotic symptoms at this time including auditory or visual hallucinations or paranoid ideation. However, after the interview she might be possibly responding to internal stimuli in her room. She otherwise denies any suicidal ideation. She denies other pertinent positives on psychiatric review of systems. The patient began asking from her room "please do not mess with my brother"...."

From 11/7/13 to 11/8/13 several staff members were interviewed regarding Patient #7 presenting on the facility grounds on 8/17/13. There were no staff members who recalled the incident. There was no documented evidence a log was completed for patients requiring emergency medical treatment after the out-patient clinic was closed for the day.

On 11/8/13 in the afternoon, it was identified which Registered Nurse (RN) house supervisor was working at the time of Patient #7's incident. The RN house supervisor recalled the incident that occurred on 8/17/13 with Patient #7. The RN house supervisor indicated the patient's case worker dropped the patient off at the facility having the understanding the patient was to be admitted to the facility. The RN supervisor indicated the facility did not receive any information the patient was transferring from a California hospital to their facility. The RN house supervisor indicated the patient could not be admitted to the facility since the out-patient clinic was closed. The RN house supervisor indicated a Legal 2000 was initiated due to his assessment the patient was unsafe and could not be left alone to wander the streets. The RN house supervisor confirmed the incident and assessment was not documented. The security guard daily log had no documented evidence of the incident. The RN house supervisor indicated there was no policy regarding handling of patients who show up to the facility when the out-patient clinic was closed.

Complaint NV00037375