HospitalInspections.org

I. Based on review of patient medical records, policy/procedures, documentation, and staff interviews, the hospital failed to follow the policies and procedures to ensure one patient (# 11) received an appropriate medical screening examination within the hospital's capabilities and capacity; and three patients (22, 29 A, and 29 B) received stabilizing treatment of their emergency medical condition within the hospital's capabilities among 45 sampled patient medical records. The hospital had an average of 4,858 patients presenting to the emergency department (ED) requesting emergency care monthly.

Failure to provide appropriate medical screening examination and stabilizing treatment may result in a delay in care with the potential to endanger the safety and life of any patient requesting care for a medical condition or an unstablized emergency medical condition.

Findings include:

1. Review of hospital policy/procedure titled "Emergency Examination and Transfer Policy - EMTALA", dated 10/2015, revealed in part, "Purpose: To establish a procedure for the examination, stabilization, and transfer of individuals coming to Unity Point Health St. Luke's Hospital emergency department and a request has been made for medical examination or treatment for a medical condition. . . ."

2. Review of a document titled "Hospital / CAH Medicare Database Worksheet" completed by the hospital during the survey indicated the hospital's capabilities included 532 inpatient beds, alcohol and/or drug services, chemotherapy services, an intensive care unit, obstetrical/gynecological services, acute inpatient psychiatric services diagnositic radiological services, surgical services, and emergency department services.

3. Review of the hospital's psychiatric capabilities per a document titled "2 East Scope of Service", last revised 8/15 revealed in part, ". . . 2 East is a 30-bed closed psychiatric unit located on the second floor. Security of the unit is ensured by double locked doors at the main entrance, locked exit doors and camera monitoring of the front entrance and key areas in the unit. The rooms in the North hall are accessed through an additional locked door and is where the most acute psychiatric patients are admitted. All rooms on the North hall are camera monitored. Patients hospitalized on 2 East are those in acute emotional crisis, psychosis, confused status or under emergency detention/court order.

Refer to tag 2406 for details on the hospital's failure to provide patient 11,with an appropriate medical screening examination; and tag 2407 for details on the hospital's failure to provide patients 22, 29a and 29b, with treatment to stabilize their emergency medical condition, within the hospital's capabilities and capacity prior to transfer or discharge.

Based on review of hospital documents, and medical records, the hospital failed to ensure one patient (# 11) that presented to the Emergency Department (ED) received an appropriate medical screening examination within the hospital's capabilities and capacity out of 45 medical records reviewed. The hospital had an average of 4,858 patients presenting to the emergency department (ED) requesting emergency care monthly.

1. Review of a closed medical record showed that Patient #11 presented to the ED on 10/13/16 at 2:57 pm complaining of suicidal and homicidal ideations. Further documentation showed patient # 11 had a history of mental illness and was non-compliant with his psychiatric medications and that the patient's past medical history included a traumatic below the knee amputation, drug abuse, schizophrenia, and a prior suicide attempt. The ED physician documented at 3:59 pm that patient # 11 stated he came to the ED because he was concerned he was going to become violent towards police because an individual called the police complaining that patient # 11 had trespassed and the officers reportedly agreed with that individual. The ED physician documented that patient # 11 was "Positive for suicidal ideas, sleep disturbance, dysphoric mood, decreased concentration and agitation."

Further documentation showed patient # 11's speech was rapid and/or pressured and tangential. He expressed impulsivity, and he expressed suicidal plans. The ED physician further documented that the patient requested a bus ticket and staff left the room to talk with the social worker about getting a ticket. The patient became upset, "He refused to take his discharge papers." "On his way out, we advised him to come back to our emergency department for any concerning condition."

Patient # 11's medical record included a note authored by one of the hospital's psychiatrists and dated three years prior (2013) to his presentation on 10/13/16 which reads in part ... [patient # 11] is "demanding and agitated on the units whenever not given anything he asks." ... "He has been given medications and follow up appointments that he never follows." ... "When provided access to shelters, he either does not go or is kicked out of them due to agitated and aggressive behaviors." "While the need for repeat psychiatric hospitalization is made by providers at each evaluation, it is the current intention of the Psychiatry Department that [patient # 11] will not be re-admitted unless there is a clear change in his mental condition."

The medical record did not contain evidence that patient # 11 received a medical screening examination sufficient to determine whether or not a psychiatric emergency condition existed or that staff attempted to get the patient to stay or explain the risks of leaving prior to completion of the medical screening examination. The hospital's capabilities included an inpatient psychiatric unit and psychiatrists that were on-call to the ED for examination and treatment of mentally ill patients.

Based on review of patient medical records, policy/procedures, documentation, and staff interviews, the hospital failed to follow the policies and procedures to ensure stabilizing treatment occurred within the hospital's capability for 3 of 45 sampled patient medical records (Patients 22, 29 a and 29 b. The hospital had a monthly average of 4,858 patients presenting to the emergency department (ED) requesting care.

Failure to provide appropriate stabilizing treatment resulted in the patients' transfer to other hospitals or discharge and delayed their treatment for an emergency medical condition.

Findings include:

1. Review of the hospital's psychiatric capabilities per a document titled "2 East Scope of Service", last revised 8/15 revealed in part, ". . . 2 East is a 30-bed closed psychiatric unit located on the second floor. Security of the unit is ensured by double locked doors at the main entrance, locked exit doors and camera monitoring of the front entrance and key areas in the unit. The rooms in the North hall are accessed through an additional locked door and is where the most acute psychiatric patients are admitted. All rooms on the North hall are camera monitored. Patients hospitalized on 2 East are those in acute emotional crisis, psychosis, confused status or under emergency detention/court order.


2. Review of a Standard Operating Procedure titled "Law Enforcement Patients" and approved by the Hospital President with an effective date of 2/2014 reads in part, Law enforcement patients can be admitted while under three types of circumstances: a. "Patient released with promise to appear", b. "Patients hospitalized under Detainee/Hold" and c. "Patients hospitalized following apprehension due to serious crime or for a patient requiring protection."

3. Review of a closed medical record revealed Patient # 22 presented to the emergency department (ED) accompanied by police on 11/21/16 at 11:58 AM complaining of muscle weakness, abdominal pain and stomach cancer.

Staff C, ED Advanced Registered Nurse (ARNP) on 11/21/16 at 1:43 PM, documented in the medical record that patient # 22 was very lethargic during the initial assessment. Further documentation showed the patient denied any recent drug use and acknowledged that he had not been taking his normal psychiatric medications as prescribed.

Staff AA, Linn County Mental Health worker, notified the St. Luke's social worker about the pending committal of Patient #22 due to deterioration in his mental condition, non-compliance with his prescribed medications and multiple calls to the Police in the last couple of weeks.

Review of the Court document signed by the local Judge November 21, 2016 at 3:59 PM (four hours after patient # 22's arrival to the ED), read in part, ... [Patient # 22] is seriously mentally impaired and is likely to injure himself or others if allowed to remain at liberty. ... [Patient # 22] shall be detained at St. Luke's Hospital ... and that said matter will be heard ... before said Court at St. Luke's Hospital on the 28th day of November, 2016 at 8:00 A.M. Further the Court document indicated the "On-Call Physician, St. Luke's Hospital" was appointed to conduct a personal examination of patient # 22 to determine whether he was seriously mentally impaired.

The affidavit in support of the Court document read in part ... patient # 22 was homeless and over the past 10 days had been arrested 3 times. His mental state was deteriorating. Further documentation showed patient # 22 had been talking about silver flakes, Martians having taken over the world, and that he was scared to eat food because he felt it was poisoned.

Review of St. Luke's psychiatric unit census information by Staff A, Director of Behavioral Health showed there were 27 inpatients (3 available beds) on the 2 East psychiatric unit on 11/21/16 and no open beds on the additionally secured North hall.

On day two of patient # 22's stay in the ED (11/22/16) at 12:03 PM, on-call Psychiatrist D evaluated patient # 22 and documented in part ... the patient was "currently homeless, living on the streets, has been refused by every shelter due to violence and does not appear to have family that can safely take him in." ... Further documentation showed that in Psychiatrist D's opinion, patient # 22 was seriously mentally impaired, unable to make responsible decisions regarding his treatment and that the patient was so violent that "our department does not have capacity to treat him on our unit" due to significant history of assaulting others. Psychiatrist D recommended patient # 22 be placed on an anti-psychotic medication, both oral and injectable ... "Placing him on an anti-psychotic is not going to fix the problem of chronic dangerousness, and subjecting my nursing staff to repeated abuse will only land [patient # 22] in jail."

At 12:09 PM on 11/22/16, the ED physician documented, "No issues during the day." "Psych saw the patient in the Emergency Room." "We are trying to get him [patient # 22] committed to [Hospital B]."

At 12:23 PM, the ED mid-level practitioner documented in the medical record that patient # 22 remained shackled with police present, patient not fighting restraints, not agitated or aggressive. Further documentation showed "Psych plan is to transfer to [Hospital B] tomorrow." ... "Have IM (intra-muscular) meds if needed for agitated (sic) but really is calm at this time."

Review of St. Luke's census information by Staff A, Director of Behavioral Health showed there were 20 inpatients on 2 East psychiatric unit (10 available beds) on 11/22/16 and three available beds on the additionally secured North hall.

On day three of patient # 22's stay in the ED (11/23/16) at 6:35 AM, Staff J, Licensed Independent Social Worker (LISW) documented in the medical record that ". . . Patient up and down throughout the night but able to be redirected when awake."

At 7:50 AM on 11/23/16, ED Registered Nurse (RN) F documented in patient # 22's medical record that St. Luke's would discharge the patient later today after a court order for admission to Hospital B was obtained. Further documentation showed that staff at Hospital B told ED nurse F that they did not have any available beds.

At 12:20 PM an ED physician documented that "no acute concerns voiced during my period of care ..." "I am concerned about this delay in care and the fact that he (patient # 22) has been restrained for so long." "He isn't 'combative' per chart/notes, but occasionally verbally disruptive so not overly concerned about rhabdo (rhabdomyolysis is a syndrome whereby dissolution of skeletal muscle is caused by direct or indirect muscle injury), etc just his autonomy." "I discussed this with the Linn County deputy [name] at 1220 who states that it is their policy and that they 'have to' keep him shackled and handcuffed unless we are doing a procedure."

At 12:35 PM on 11/23/16 an ED nurse documented in the medical record that he informed St. Luke's Behavioral Health Director that Hospital B reported they did not have any available beds. Further documentation showed that the Behavioral Health Director "replied that if they show up at [Hospital B] with the patient, it has been his past experience that [Hospital B] will 'find a bed.'" Further documentation showed that the Behavioral Health Director "directed that transportation be called to transfer."

At 12:45 pm, the ED nurse documented that staff at Hospital B "continues to state that they do not have a bed available at this time."

Review of St. Luke's census information by Staff A, Director of Behavioral Health showed there were 20 inpatients on 2 East psychiatric unit on 11/23/16 (10 available beds) and four available beds on the North hall.

During an interview on 1/5/17 at 10:20 AM, Other Staff AA, Linn County Mental Health Advocate, stated Patient #22 could get very violent but this time the patient was not anywhere near as violent as in the past.

Review of Hospital B's medical record revealed patient # 22 arrived on 11/23/16, was admitted to an open unit with other patients and did not require restraints or additional security.

The evidence in the medical record indicated St. Luke's Hospital did not provide within its capabilities and capacity stabilizing treatment to patient # 22 who had an un-stabilized emergency medical condition from 11/20/16 through 11/23/16. The hospital's on-call psychiatrist documented refusal for inpatient admission on 11/22/16 and sought a court order for transfer to another acute psychiatric hospital even though beds were available in the psychiatric unit along with the presence of law enforcement and/or hospital security in the event patient # 22's behavior became violent.

4. Review of a closed medical record showed that patient # 29(A) presented to the ED on 11/28/16 at 9:42 am complaining of increased shortness of breath, dizziness, lightheadedness and profuse vaginal bleeding since last night (11/27/16). Documentation by the Advanced Registered Nurse Practitioner (ARNP) S at 10:20 am indicated patient # 29(A) had a previous admission to St. Luke's Hospital in October for treatment of a blood clot in her lung and right lower extremity and received a prescription for Xarelto (blood thinner) at that time. Further documentation showed that patient # 29(A) reported being lightheaded when getting out of bed this morning and had a large gush of blood from her vagina with several clots. Patient # 29(A) also reported having an appointment to see her OB/GYN (obstetrician/gynecologist) in one month. In the ED notes, ED nurse Q documented that patient # 29(A) had a large amount of bright red vaginal bleeding with clots present; that patient # 29(A) appeared dyspneic (difficulty breathing) with even mild exertion; was pale, cool to the touch with dry mucous membranes that were also pale; and reported mild to moderate low pelvic discomfort.

During the examination, ARNP S documented there was bleeding in the patient's vagina. Blood for testing obtained at 10:36 am showed that patient # 29(A) had an abnormally low hemoglobin of 8.5 (normal 12.2-15.6 g/dL). At 10:06 a.m., ARNP S ordered one-liter bolus (rapid infusion) of normal saline intravenous (IV) fluid. At 10:08 a.m., patient # 29(A) underwent a trans-vaginal ultrasound, which identified multiple uterine abnormalities. Further documentation indicated ARNP S contacted the on-call OB/GYN who requested to see the patient in their office tomorrow (11/29/16) at 1:45 p.m. for an endometrial biopsy.

At 1:10 pm ED nurse Q documented patient # 29(A) got up, went to the bathroom to change her peri pad, and reported she was "bleeding again," but is manageable at this point." At 1:42 pm patient # 29(A) was discharged with instructions to follow up with gynecology the next day for a biopsy, and to return if bleeding continued.

The medical record did not contain evidence that the hospital stabilized patient # 29(A)'s emergency medical condition, active bleeding while taking an anticoagulation (blood thinning) medication, prior to discharge from the ED.

5. Review of a second closed medical record indicated patient # 29(B) returned to the ED by ambulance at 9:11 pm on 11/28/17, approximately 7 hours after discharge for continued vaginal bleeding. Documentation in the medical record on the Pre-Hospital Care Report Summary indicated patient # 29(B) requested transport to St. Luke's Hospital. Upon arrival, the paramedics documented patient # 29(B) was pale, sweating, had a low blood pressure 108/palpable - meaning the diastolic pressure was too low to determine (normal 120/80), a rapid heart rate of 134 (normal 70-100) and were unable to establish intravenous (IV) access. Further documentation showed the patient arrived at the ED at 9:08 pm on 11/28/17.

ED physician R documented patient # 29(B) had a history of blood clots in the lungs, had been prescribed long term use of anticoagulant medication (to prevent blood clots from forming) and was currently experiencing uterine bleeding possibly due to cancer. Further documentation showed patient # 29(B) stated she was scheduled to have a biopsy tomorrow with OB (obstetrics) for concerns of cancer. At 9:21 pm, blood obtained for testing indicated patient # 29(B)'s hemoglobin was 7.3 g/dL down from 8.5 g/dL prior to discharge from the ED earlier in the day. The ED physician ordered 2 units of blood for immediate transfusion. Further documentation showed the ED physician R talked to the gynecologist on-call, "he recommended that the patient be transferred to Hospital D for further evaluation and treatment." During the blood transfusion at 11:12 pm, patient # 29(B) was transferred to Hospital D.

The evidence in the medical record indicated patient # 29(B) had an emergency medical condition (EMC) that was not stabilized within the hospital's capabilities, continued blood loss while taking a blood thinning medication. The benefits of transfer were "need for diagnostic equipment/tests" which did not outweigh the risks of "bleeding/shock; loss of limb and/or fracture complications; additional delay in receiving appropraite treatment" as documented in the medical record. The on-call GYN physician did not come to the ED to examine the patient. St. Luke's Hospital had the capabilities including but not limited to, 532 hospital beds, an on-call GYN physician, an on-call surgeon, on-call hospitalists, a cancer treatment center, a medical/surgical intensive care unit, and diagnostic radiology services.