HospitalInspections.org

Based on review of Emergency Medical Services Documents, Emergency Department (ED) Logs that included the Main Medical Emergency Department (MMED), Obstetric (OB) Unit and Behavior Health Emergency Department (BHED), Medical Records, Medical Staff ByLaws, Medical Staff Rules and Regulations, On-Call Schedules and interviews, it was determined the facility failed to ensure one patient (#6) out of 20 ED patient charts reviewed, received stabilizing treatment after a change in condition occurred while in the facility's BHED, for example refer to A-2406.

Based on interview, record review, and policy review, the facility failed to ensure each patient that presented to the facility's Behavioral Health Emergency Department (BHED) received a Medical Screening Examination (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for one (#6) out of 20 patient records reviewed. This had the potential to affect all patients that presented to the facility's BHED. The facility's BHED average monthly census was 475 and the average monthly patients transferred were 1.16.

Findings included:

1. Record review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Active Labor Act): Emergency Medical Screening/Emergency Department Call Coverage," dated 06/24/14, showed that a Medical Screening Examination:
- Refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists.
- Such screening must be done within the facility's capability and available personnel, including on-call physicians and other Qualified Medical Persons (QMP).
- The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred.

Record review of the facility's policy titled, "Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar)," dated 11/11/13, showed the following information:
- Practitioner (Physician/Psychiatrist/Nurse Practitioner) orders the CIWA-Ar order set which will initiate the CIWA-Ar protocol and trigger assessment tasks to appear in the electronic medical record. Upon receiving the order to initiate the CIWA-Ar protocol
- The CIWA-Ar scale is a validated 10-item assessment tool that is used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate clients going through withdrawal in a safe environment under the supervision of a physician, psychiatrist, nurse practitioner, and monitored by a registered nurse.
- Place patient on seizure and fall precautions.
- The 10-items staff is to assess when a patient is on CIWA-Ar included:
- Nausea/Vomiting;
- Tremors;
- Anxiety;
- Agitation;
- Paroxysmal Sweats;
- Orientation and Clouding of Sensorium;
- Tactile Disturbances;
- Auditory Disturbances;
- Visual Disturbances; and
- Headache, Fullness in Head.
- The Nausea/Vomiting (0 - 7) Scale assessment included:
- Ask patient: Do you feel sick to your stomach? Have you vomited?
- Observation: 0 - none; 1 - mild nausea, no vomiting; 4 - intermittent nausea with dry heaves (an involuntary act of vomiting without material); 7 - constant nausea, frequent dry heaves and not extended.

Record review of Patient #6's medical record showed the following timeline:
- On 05/28/15 at 7:49 PM, the patient presented to the Main Medical Emergency Department (MMED) with complaints of alcohol intoxication and suicidal ideations (SI-thoughts of suicide).
- On 05/29/15 at 3:18 AM, the patient was transported from the MMED to the BHED.
- On 05/29/15 at approximately 1:00 PM, the patient was found unresponsive, CPR (cardiopulmonary resuscitation) was initiated, 911 and the Code Blue Team (staff trained in advanced cardiopulmonary resuscitation) was called.
- On 05/29/15 at 1:27 PM, the patient was transported from the BHED to the MMED per ambulance.
- On 05/30/15 at 6:55 PM, the patient expired.

Record review of the patient's MMED showed:
- On 05/28/15 at 7:49 PM, the patient presented to the MMED per ambulance with complaints of drinking an unknown amount of alcohol along with taking three pills with the letter "V" in an attempt to "end it all."
- On 05/28/15 at 8:48 PM, the patient's Blood Alcohol Level (BAL) was 393 (normal range is 0-10 and a BAL of 300 to 400 is potentially fatal) and the physician was notified.
- On 05/29/15 at 1:02 AM, the patient received a consult by the Qualified Mental Health Practitioner (QMHP) that recommended he be transferred to the BHED for psychiatric evaluation due to SI, substance abuse and detox (a process to prevent alcohol withdrawal, which can be a life-threatening condition due to heavy drinking. Sudden withdrawal can cause severe complications such as seizures).
- On 05/29/15 at 3:18 AM, the patient was transported from the MMED to the BHED.

During an interview on 07/15/15 at 1:50 PM, Staff N, Physician, Chair of the ED, stated that:
- The MMED did not use the CIWA-Ar protocol.
- The MMED did not have an alcohol detox protocol.
- Alcohol detox was based on the ED physician's clinical judgment.

During an interview on 07/15/15 at 2:30 PM, Staff S, BHED Registered Nurse (RN), stated that:
- She cared for Patient #6 on 05/29/15 the day of the incident.
- The patient was admitted for alcohol withdrawal.
- The patient had a trach that did not require oxygen to it.
- Sometime during her shift she received an order to start the CIWA-Ar protocol that included seizure and fall precautions.
- She did not receive report that the patient had any respiratory problems with his breathing or trach.
- It was not common to have patients admitted to the BHED with a trach.
- She felt comfortable with suctioning patients with or without trachs if they needed to be suctioned.
- The BHED had only one Yankauer (a tool used to clear oral saliva and mucous from the mouth) suction catheter but no suction tubing was available for deep suctioning.
- Trach kits (supplies needed to care for a trach) were not available in the BHED.
- The Mental Health Technician (MHT) reported to her that the patient had vomited.
- The patient stated that he thought he vomited because he was coming off alcohol.
- The patient was a little pale in color and his breathing was a little labored and "vigorous".
- She did not assess the patient's respirations when she noticed a change because she did not consider his breathing as a concern.
- Approximately 20 minutes later the patient took his oral medications and laid down on his mat (patients are placed on mats on the floor when the BHED exceeds their 10 bed capacity) on the floor on his right side.
- The patient should have been on seizure precautions and she did not know if patients on seizure precautions needed their head elevated up on pillows.
- She went to the break room for a couple of minutes and when she returned the Clinical Team Manager (CTM) reported that she noticed a change in the patient's condition. The patient's eyes were "rolled" back and his abdomen was distended.
- When staff tried to bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) the patient, air would not go through his mouth or trach.
- She was definite the patient's trach was obstructed (blocked making it hard for air to move) and stated what could we (staff) do since suction tubing to do deep suction was not available and the Yankauer suction catheter would not be effective for his trach?
- Staff placed the mask (used to deliver oxygen) over the patient's nose and mouth to deliver as much air as possible.
- After several attempts were made to deliver air to the patient were unsuccessful, the MMED physician (the MMED physician was a member of the Code Blue Team that responded to the code) stated that the patient was "obstructed" and needed to be transported to the MMED as soon as possible.
- She did not feel like the trach being obstructed helped the outcome of this patient.

Staff S, BHED Staff RN, failed to reassess the patient or report such findings to the physician after the patient experienced a change in status after he vomited. During an interview Staff S stated that the patient's color was a little pale and his breathing was a little labored and "vigorous," but she did not assess his respirations when she noticed the change because she did not consider the change as a concern.

During an interview on 07/15/15 at 9:50 AM, Staff K, Medical Director of Psychiatric Services, stated that:
- He expected staff to assess a patient's airway if a patient experienced respiratory distress.
- He expected staff to suction a patient if they needed it.
- He did not recall how common it was to admit patients with a tracheostomy (trach-a surgical procedure used to create an opening through the neck into the trachea [windpipe] to assist with breathing).
- Just because the patient had a trach would not exclude him from admission to the BHED since he had been medically cleared and the patient performed self care of his trach outside the facility.
- Code Blue situations were not common in the BHED.
- The MMED and the BHED were considered one ED.
- For patients placed on seizure precautions he expected the following measurers to be implemented: Mats should be on the floor around the bed and the patient's head should be elevated up on pillows.

Record review of the Behavioral Health ED Evaluation by Staff EEE, Behavior Health Unit Psychiatrist showed a late entry after the patient was transported to the MMED on 05/29/15 at approximately 1:22 PM. The documentation was dated 05/29/15 at 2:46 PM.
- Identification Data and Reason for Evaluation: The patient has a long history of chronic (persisting for a long time) alcohol dependence, came to our emergency room (BHED) at the referral of the MMED for safe medical detox and reported suicidal ideation. The patient reported drinking an unknown amount of alcohol and took three pills that start with the letter "V", in an attempt to end it all. Reportedly was medically evaluated/cleared and transferred to our facility around 1:00 AM today. With several patients in the BHED ahead of the patient, he could not be evaluated by the night shift resident physician, and ultimately was seen by me (Staff EEE) around 10:30 AM today. The patient's blood alcohol level was 393 on 05/28/15 at 7:58 PM. (This is inconsistent with the record from the MMED, which showed the BAL was reported at 8:48 PM).
- History of Presenting Illness: The patient reported he is homeless, drinks regularly and has not taken his medication for a couple of days. The patient stated that he wanted to drink himself to death.
- Medical Issues: The patient has a history of hypertension (high blood pressure), seizure disorder, withdrawal seizures (occurs when alcohol consumption is stopped), hepatitis C, diabetes and vocal cord paralysis leading to tracheostomy.
- Plan: Recommended hospitalization for a safe medical detox and for reported suicidal statements. Will place him on CIWA protocol. Planned orders for above medication/detox placed secondary to nursing reports that there will be an inpatient psychiatric bed available right now (planned orders are to be carried out for medications and CIWA protocol when the patient is admitted to the BHU).
- Added Note: Patient reportedly was noticed unresponsive by a Registered Nurse around 1:30 PM. CPR initiated along with oxygen. A Code Blue Team was called (the patient was taken to the MMED by ambulance at 1:22 PM).
- "I was informed by nursing at a much later time that the patient reportedly had an episode of vomiting after lunch today with no hematemesis (blood in vomit) or retching (dry heaving). The patient reportedly claimed he was doing fairly well and did not want any medications for nausea/vomiting. The patient reportedly took his seizure medicine without any problem 30 minutes after vomiting and reportedly appeared to be doing fairly well; reportedly he did not exhibit any overt alcohol withdrawal symptoms during contacts."

Record review of the patient's Power Orders (electronic physician orders)showed Staff EEE ordered the Behavioral Health Hospitalization, Withdrawal (CIWA) Planned orderset on 05/29/15 at 11:32 PM.

Record review of the patient's BHED Multidisciplinary Documentation (Nurse's Notes) showed: (this documentation was entered in the patient's BHED record after he was transported to the facility's MMED on 05/29/15 at approximately 1:22 PM):
- On 05/29/15 at 1:26 PM, the patient was administered Keppra (medication used to treat seizures) 1000 milligrams (mg) and Metformin (medication used to treat diabetes) 500 mg and taken per mouth by the patient.
- On 05/29/15 at 1:26 PM and 1:41 PM, staff documented the patient's CIWA score was zero (per the MHT report, the patient vomited after lunch but this was not reflected in the CIWA score documented by staff).
- On 05/29/15 at 2:28 PM, the patient threw up as reported by the MHT (there is no documentation of the time the patient vomited). The patient had just eaten lunch and denied retching or blood in the vomit. The patient denied any need for medication and laid down to rest. The psychiatrist was notified.
- On 05/29/15 at 1:26 PM, (time contradicts other documentation) the patient rested on a cot (mat on the floor) on his side at 1:00 PM with his eyes open and skin diaphoretic (sweaty). When staff attempted to arouse him, he did not respond. His breathing was shallow and barely noticeable to fingers from his mouth and trach. His pulse was thready (a pulse that is difficult to feel or disappears easily with slight pressure) and CPR was initiated.
- 911 was called at 1:01 PM and paramedics arrived at approximately 1:05 PM.
- No vital signs (blood pressure, pulse, respirations and temperature) or oxygen SATs (saturation, which is the oxygen level in the blood) registered
on equipment.
- The Code Blue Team was called at 1:07 PM and arrived sever minutes later.
- Glucometer (machine used to measure blood sugar) read 195 (normal reading after meals is 180).
- The patient left per ambulance at 1:22 PM.

Record review of the patient's BHED record showed that staff:
- Did not include in the CIWA assessment score that the patient had experienced an episode of vomiting after lunch as reflected in a documented CIWA score of zero.
- Did not document that they assessed the patient after he experienced an episode of vomiting with a change in his color and respiratory status.
-Did not document that they reported the patient's change in status to his physician and/or psychiatrist.
- Did not document that they assessed his airway or condition of his tracheostomy to ensure his airway was clear and to rule out if he experienced an EMC.
- Did not document that they attempted to suction either the patient's mouth or trach when he experienced an EMC related to respiratory distress and failed attempts to deliver oxygen to the patient.

Record review of the patient's medical record from the MMED showed:
- On 05/29/15 at 1:37 PM, the patient arrived at the MMED.
- At 1:39 PM, the patient's trach cannula was exchanged for a 6.0 Shiley (size of a trach cannula). Breath sounds positive.
- At 1:56 PM, noted obstruction (blockage) present in patient found by Staff R, Senior Attending Emergency Physician (staff documented this after the patient's trach cannula had been changed at 1:39 PM).

During an interview on 07/15/15 at 11:45 AM, Staff R, Senior Attending Emergency Physician, stated that:
- When the patient arrived in the MMED he was "hard" to bag so staff replaced the plastic cannula.
- After the cannula was replaced the patient was easier to bag and his breath sounds were audible.
- She did not recall any obstruction with the patient's trach but when the cannula was replaced by staff he was easier to bag.
- The patient's trach stoma (opening into the windpipe) was "crusty" in appearance.
- She expected staff to re-assess a patient's airway after a vomiting episode.

During an interview on 07/15/15 at 3:15 PM, Staff T, Clinical Operating Officer BHED, stated that she expected staff to provide quality of care in a safe environment and standards of practice used (how similar qualified practitioners manage care under the same/similar circumstances).

During an interview on 07/15/15 at 3:45 PM, Staff V, Chief Executive Officer, stated that he expected staff to provide standards of care in a safe environment. Staff V stated that he expected the standards of care to be practiced at both the MMED and BHED.

Record review of the MMED physician orders dated 05/29/15 at 2:32 PM, showed an order for Critical Care, upper respiratory tract obstruction/cardiopulmonary arrest. The patient expired on 05/30/15 at 6:55 PM.