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Based on findings documented in data tag 2407, the hospital failed to comply with requirements of 42 CFR 489.24.

Based on observation and interview, the hospital failed to conspicuously post a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. There were no signs observed in the waiting room or treatment areas of the Family Birth Center. Findings:

On 5/27/10 at 10:45 a.m., during a tour of the Family Birth Center with the director of emergency services and the director of the Family Birth Center (DFBC), no signs specifying rights to have treatment and examinations were observed in the waiting area. When asked about the signage, the DFBC referenced a sign at the outside entrance to the waiting area. It was located below handrail level on the left side of the entrance and could not be viewed from any of the chairs in the waiting area. DFBC stated there was no other signage in any of the treatment areas.

Based on interview and documentation, the hospital failed to ensure the central log which tracks patients who request emergency care was maintained, and provided for review in a timely manner. The hospital failed to ensure the emergency room (ER) central log contained the required information for two sampled patients (24 and 29). Patient 24's discharge home was not documented on the ER Log. Patient 29's discharge disposition on the ER Log was inconsistent with the patient's other medical record information. Findings:

1. The hospital received patients requesting emergency care through the emergency room and labor and delivery department. Logs were kept to track of those patients who presented in these areas.

On 5/25/10 the hospital central log for individuals seeking emergency care was reviewed. Administration presented an emergency room (ER) log and labor and delivery log. During the review and selection process of patients, it was noted that some patients were being serviced at an area known as "CDU." When asked about this, the emergency department manager said it was a critical decision unit (CDU) for emergency room patients. She further stated it was part of the emergency room which maintained a separate log regarding the disposition of the patient. This log was then requested.

While still selecting patients for review, it was also noted that patients who left the emergency department without being seen were missing from the log. The ED manager stated they had a separate log for these patients. This log was requested for review. The log did not include when the patient arrived or was first noted to have left without being seen.

After selecting the patients for review and obtaining the charts, it was found the logs did not include when patients arrived or left (left without being seen log) and disposition/transfer of the patient (main emergency room log).

On 5/26/10 when these errors were presented, the hospital produced another log which included the required components but had not been presented to the evaluators in a timely manner. It was unclear which log the hospital used for what purpose.



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2. Patient 29's record was reviewed on 5/27/10 at 10:50 a.m. with the director of emergency services (DES). Patient 29 was seen in the ER on 4/8/10 at 3:14 p.m. for alcohol intoxication and was cleared for discharge to jail. Patient 29's disposition in her clinical record indicated she was transferred to jail. A review of the computer generated ER sheet indicated she was discharged to home. The DES stated, "That is a clerical error".

Patient 24's record was reviewed on 5/27/10 with the DES. Patient 24 was admitted to the ER on 4/4/10 at 8 p.m. for alcohol intoxication and schizophrenia (a chronic, severe mental disorder). The clinical record indicated Patient 24 was brought in by ambulance after falling in front of a local store. After initially being cooperative, Patient 24 began to yell obscenities, refused medication, pulled out his intravenous line, and started to get dressed. The physician was notified. Patient 24 was given a cab voucher and discharged to home without any discharge instructions. The ER Log gave no disposition, but the computer generated log indicated he was discharged to home.

Based on interview and record review, the hospital failed to stabilize a patient (1) in the emergency department (ER) prior to discharge. The patient was released from a California Welfare and Institutions Code (W&I) 5150 (72 hour hold for mentally disordered persons for evaluation and treatment) and discharged from the ER without physician assessment of the patient's psychiatric condition. Findings:

Patient 1 was admitted to the ER on 5/20/07 at 4:49 a.m. He had been brought to the ER by the police, after an altercation with the police. The police tasered (applied electric shock) to Patient 1 prior to his arrival and brought him to the ER for evaluation and treatment of the patient's mental status and medical clearance. A review of the ER clinical record indicated a W&I Code 5150 was completed by the police on 5/20/07 because the patient was a danger to himself and others.

Patient 1's record was reviewed on 5/25/10 at 9:30 a.m.

The clinical record indicated Patient 1 was initially cooperative but had been placed in four-point restraints at 5:40 a.m. with police at the bedside. Patient 1's hospital progress notes and restraint narrative indicated Patient 1 was biting, threatening physical assault to staff members, trying to assault, and screaming threats and insults. A review of the clinical record indicated Patient 1's behavior remained violent when awake throughout his ER stay. A restraint narrative written on 5/20/07 at 1:30 p.m., indicated his behavior remained violent and the police were present. The last restraint narrative and progress note at 2:30 p.m., indicated his restraints were removed at the time of his release, but had no documentation about Patient 1's behavior or mental state.

A review of Patient 1's physician's orders indicated orders for intravenous fluids, blood laboratory tests including an alcohol level and a urine drug screen at 5:35 a.m. Four-point restraints were ordered at 5:40 a.m. There were physician orders for Ativan (a drug used to sedate patients or treat anxiety), Haldol (an antipsychotic drug), and Benadryl (an antihistamine with a sedative side effect). These medications were given between 5:40 a.m. and 7:30 a.m. Ramazicon (used for reversal of the sedative effects of benzodiazepines- depressants administered therapeutically to produce sedation) were ordered and given at 9:10 a.m. and again at 9:12 a.m.. A urine drug screen was not done prior to Patient 1's discharge, and had not been discontinued from Patient 1's physician's orders.

On 5/26/10 at 12:40 p.m., during an interview the psychiatric consultant (MD 1), he stated he remembered Patient 1. He went to the ER to evaluate Patient 1 three times and found him too somnolent (non-responsive) to interview. On the fourth trip to evaluate Patient 1, the nurse was able to arouse Patient 1, who immediately began to verbally taunt the policeman present at the doorway and to threaten the nurse. MD 1 stated his exam lasted about five minutes but the patient was too agitated to answer questions.

MD 1 stated he remembered being asked, but could not recall who asked him to release the W&I 5150 hold so that Patient 1 could be released to jail. MD 1 stated he released the hold at 1:30 p.m., one hour prior to release of the physical restraints and Patient 1's discharge. MD 1 stated he felt jail was a transfer to a higher level of care since jails have facilities to observe the patient without necessarily restraining him in four point restraints. MD 1 stated he had every reason to think Patient 1 was going to jail when he saw the police outside the room. MD 1 stated he would not have released the W&I 5150 hold if he knew Patient 1 was not going to jail.

During the interview on 5/26/10, MD 1 reviewed the hospital's 4/06 policy and procedure for Emergency Department, Violent Patients or Patients with Aggressive Behavior Special Precaution. The policy and procedure indicated, "Patients who remain irrational or violent and aggressive after treatment will be admitted or transferred to another institution with restraints as indicated. The Crisis Team Member or Psychiatrist (or Emergency Physician) may initiate a W&I 5150 hold for irrational, violent or aggressive patients, if not indicated by law enforcement officer." After reviewing this policy, MD 1 stated if he had known, he would have left the patient on the W&I 5150. MD 1 stated, "He (Patient 1) was too sick to go".

During interview on 5/26/10 at 1:40 p.m., the hospitalist consultant (MD 2) stated he wrote the discharge orders as a courtesy. MD 2 stated he was only the consultant and it was the ER MD who was in charge of the case. MD 2 recalled spending a lot of time on the phone between two police departments, but both police departments refused to arrest Patient 1. MD 2 asked the local law enforcement to walk Patient 1 out of the ER because he had threatened staff.

A review of the 5/20/07 discharge orders by MD 2 indicated Patient 1 was medically released. MD 2 recommended at least 24 hours jail detainment for public safety factors, but left the decision to detain the patient up to the local police department.