HospitalInspections.org

Based on patient clinical record review and staff interview, it was determined that the facility failed to ensure that one emergency room patient (#6) who was determined to have an unstable emergency medical condition, which was psychiatric in nature, was provided further medical treatment within the capability of the hospital. The total patient sample was 20 emergency room patients. The average number of patients seen in the emergency department per day is 150.

Findings include:

Review of the clinical record for patient #4 was completed on 3/3/10. The patient was seen in the emergency department (ED) of the named hospital on 2/16/10 for a psychiatric emergency (non-fatal drug overdose/suicide attempt) and was deemed to be at risk for additional suicide attempts. She arrived in the ED at 2:37 PM accompanied by her mother and brother, was triaged at 2:43 PM, and was admitted to an ED bed at 2:52 PM. She was seen by the ED physician at 3:07 PM. Family remained at the patient's bedside and suicide precautions were in place. This hospital has a psychiatric RN or psychiatric nurse practitioner (CNP) available from 8:00 AM until 11:00 PM. The patient was seen and evaluated by the psychiatric CNP beginning at 3:59 PM. The patient had taken a handful of Xanaz, Klonopin, and Percocet on 2/15/10, and when she awakened on 2/16/10 and realized she had not died she took some Valium and Percocet. She was at first drowsy when admitted to the ED, but oriented and cooperative; later notes observed the patient to be alert. She required no medical intervention for the overdose. Her only treatment in the ED was to receive intravenous fluids. Labs were drawn, including blood chemistries, a hepatic panel, complete blood count with differential, and a urinalysis. She tested positive for benzodiazapines and opiates. It was determined that the patient was medically stable; however, the psychiatric CNP determined that she remained at risk for suicide, was suffering from acute depression, and required inpatient psychiatric hospital care. The psychiatric CNP advised the ED physician of her findings.

The patient was placed on a 72 hour hold. The patient clinical record included a form, signed by the ED physician, called Form A - Statement at Time of Admission by Transporting Psychiatrist, Licensed Psychologist, Licensed Physician, Health or Police Officer, or Sheriff. This form was signed by the physician and items were checked that indicated the patient: "represents a substantial risk of physical harm to himself as manifested by evidence of threats of or attempts at suicide or serious self-inflicted bodily harm;" and "would benefit from treatment in a hospital for his mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or himself."

This hospital has an inpatient psychiatric unit. However, according to interview with the ED director on 3/2/10 and the psychiatric CNP on 3/3/10, when the psychiatric CNP checked the patient's psychiatric medical insurance, it was discovered that the hospital was out of network for the insurance. The psychiatric CNP stated that the social worker contacted a hospital approximately two miles away which also has an inpatient psychiatric unit, and that hospital confirmed that they were in network for the patient's insurance. The psychiatric CNP then contacted the second hospital and the patient was accepted by a physician for admission there.

According to the interviews with the ED director and the psychiatric CNP, the patient as well as her family agreed with the transfer. However, notes by the psychiatric CNP stated only that the patient was discussed with the physician and that the insurance was out of network and the patient would need transfer to another facility if medically stable. Notes by the physician stated that the patient was evaluated by the psychiatric intake nurse and that it was found that her insurance was out of network [here] but was in network at a second hospital. The documentation on the Inter-Hospital Transfer Form showed that the reasons for transfer were "insurance" and "other." The patient had signed the form, but the boxes indicating the patient accepted the transfer and/or requested the transfer were not checked.