HospitalInspections.org

Based on record review, document review, and staff interview, it was determined the facility failed to stabilize the patient (see tag A 2407). This failure has the potential to negatively impact all patients receiving Emergency Care at the facility.

Based on medical record review, document review, and staff interview, it was determined the facility failed to stabilize and effectuate an appropriate transfer of a patient to another medical facility, for one (1) out of twenty (20) patients, (Patient 1). This failure has the potential to negatively impact all patients presenting to the Emergency Department (ED) for treatment.

Findings include:

A medical record review was conducted for Patient 1. Patient 1 arrived in the facility's ED on 6/21/23 at 5:31 p.m. via private vehicle. Patient 1 was brought to the ED following an altercation with family members and jumping out of a window; law enforcement was contacted but Patient 1 arrived at the ED in parental custody.

An "ED Triage" note completed by Registered Nurse (RN) 1 on 6/21/23 at 5:45 p.m. states that Patient 1 had been aggressive throughout the day while staying with grandparents. Parent was called and Patient 1 was brought to the ED for evaluation.

An "ED Triage" note completed by RN 1 on 6/21/23 at 6:24 p.m. explains that Patient 1 has a history of Williams Disease [a genetic condition that is present at birth, characterized by medical problems, including cardiovascular disease, developmental delays, and learning challenges] and autism and was uncooperative and threatening at the time of arrival. Vital signs were not taken because Patient 1 was uncooperative.

The "ED Primary Provider Note History of Present Illness", dated 6/21/23, indicated Patient 1 had been violent, aggressive, and screaming inappropriate phrases. The provider further documented Patient 1 would be hard to place [for treatment]; the parents were offered the option to take the patient to a different hospital emergency room (ER) after the patient calmed down. Haldol and Ativan (benzodiazepines, a class of medication commonly used for sedation, anxiety, and seizures) were given twice, and then given Morphine, and the patient was transferred in a private vehicle to the other hospital.

An "ED Nurses Note" completed by RN 2 on 6/21/23 indicated the patient's parent was provided with discharge instructions to take to the other facility and verbalized understanding of the instructions. No problems were identified during the discharge process.

A review conducted of the policy, titled "Emergency Medical Treatment and Labor Act (EMTALA) policy", reviewed 9/22/22, stated in pertinent part: "Purpose: To insure that (1) all patients who present to (facility name) or its premises requesting emergency services receive an appropriate Medical Screening Examination; (2) patients with an emergency medical condition are stabilized; (3) patients requiring or requesting transfer are transferred appropriately; (4) that departments providing emergency treatment are prospectively aware of which physicians are available on call to provide necessary treatment; (5) through adequate signage, insure that all patients have the opportunity to review their right to medical screening examination and stabilization for an emergency medical condition, as required by the Emergency Medical Treatment and Labor Act ("EMTALA"), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder."

Review of the Drugs.com "Drug Interaction Report" indicated combining Haldol with Morphine, or other Central Nervous System (CNS) depressants, should generally be avoided and could cause the following side effects: Profound sedation, respiratory depression, coma and death (retrieved from https://www.drugs.com/interactions-check.pho?drug_list=1230-729,1656-0&types%5B%5D%=major&types%5B%5D%=minor&types%5B%5D%=moderate&types%5B%5D=food&types%5B5D=therapeutic_duplication&professional=1).

Review of the Drugs.com "Drug Interaction Report" indicated combining Ativan with Morphine, or other CNS depressants, should generally be avoided and could cause the following side effects: Profound sedation, respiratory depression, coma, or death (retrieved from https://www.drugs.com/interactions-check.pho?drug_list=1230-729,1656-0&types%5B%5D%=major&types%5B%5D%=minor&types%5B%5D%=moderate&types%5B%5D=food&types%5B5D=therapeutic_duplication&professional=1).

An interview was conducted with Physician 1 on 6/29/23 at 10:00 a.m. Physician 1 stated Patient 1 showed no change after the administration of the first dose of medications [Haldol and Ativan] and was given a second dose of both medications again, with no improvement. Physician 1 stated they ordered Morphine then, since they had seen a similar patient calm after the administration of Morphine, and this also worked for Patient 1. Physician 1 stated they did not consult with telepsychiatry services available at the facility because they felt the patient needed inpatient psychiatric treatment.

A second interview was conducted with Physician 1 on 6/30/23 at 10:00 a.m. via telephone. Physician 1 was unable to provide standards of practice regarding the use of Ativan, Haldol and Morphine in combination.

There was no documentation the physician provided stabilizing treatment for the patient's emergency medical condition, contacted the other hospital ER to discuss the pending arrival of the patient, or provided appropriate personnel to monitor a patient sedated with opioids and benzodiazapines while being transported in a private car.