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 (#2) 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 22 emergency room patients. The average number of patients seen in the emergency department per day is 79.

Findings include:

Clinical record review for patient #2 was completed on 9/15/10. The nurses triage notes stated that the patient was triaged in the emergency department (ED) on 8/26/10 at 6:45 PM and admitted to room 4 at 6:53 PM. She was accompanied by her mother. The chief complaint for the 21-year-old patient was noted in the nurses triage note to be anxiety, depression, sleeping difficulty, anger, and hostility. The family stated this started 30 days previously and that the patient had been taking drugs, and was very angry and hostile. The past medical/psychiatric history was noted to include anxiety and bipolar disorder. Home medications were stated to be Celexa and Atarax.

The emergency physician noted that his examination of the patient took place in room 4 at 6:15 PM. The physician noted the chief complaint as depression and agitation, existing for years but increased for five months and worsening since a motor vehicle accident the previous weekend. Associated symptoms were noted as depression, anger, agitation, and hostility. The patient was noted to be taking Celexa and Atarax, and the physician indicated that the mother had also found Klonopin and marijuana.

The physician ordered a CT scan of the head, a blood alcohol level, and a urine drug screen. The only positive result was that the drug screen was positive for benzodiazepines.

A crisis assessment was ordered at 7:30 PM. The crisis assessment was performed at 8:00 PM on 8/26/10 by staff C, who was one of a team of specially designated hospital staff who were present in the hospital from 12:00 PM until 12:00 AM daily. Staff C wrote in her assessment that the patient had a history of bipolar disorder, anxiety, and ADHD. The patient reported having stopped taking her Celexa and Atarax some time previously. The patient reportedly was seen at another hospital four days previously, and was released and given a prescription for Xanax. The mother noted the patient's mood swings, irritability, and aggression. She stated there were two motor vehicle accidents in the past two weeks, and because of this she had checked the patient's purse and found Benadryl, THC, Klonopin, and caffeine pills. Alcohol and/or drug use were assessed and mental status was assessed: of note, judgment was checked as impaired. A Lethality Assessment was completed and was unremarkable. Physician and psychiatrist contact were checked as N/A. Disposition/Intervention was checked as educated on community resources.

On 9/14/10, the first day of the survey, staff C wrote an addendum to her notes that further stated she contacted the psychiatrist on call to provide the assessment findings, and that the recommendation was made to transfer the patient to another area hospital. Staff C called the second hospital with the findings and reported that the hospital was not accepting outside admissions due to low staffing. Staff C spoke with the ED physician at the first hospital, and wrote that he indicated that since the patient's condition had improved, he would give the mother the option of holding the patient in the ED or medicating the patient and taking her home. There was no notation that the psychiatrist was consulted again after the second hospital refused the transfer of the patient. The mother chose to take the patient home, with the understanding that if the symptoms continued she could return the patient to the ED at the named hospital.

Further review of the ED physician notes indicated he wrote that as a result of the crisis evaluation the hospital would try to have the patient transferred to the other area hospital for admission and inpatient treatment. However, at 11:30 PM the physician noted that the other hospital would not accept the patient and the mother agreed to observe the patient at home with follow-up at the second hospital. The physician notes also indicated that the disposition was that the patient was transferred to the second hospital. The notes did not state what the patient's condition was upon discharge (boxes on the ED physician form were labeled unchanged, improved, or stable, but none of these boxes were filled in). The physician did not indicate on his notes that the patient had had a change in condition that warranted discharge instead of psychiatric inpatient admission, nor that the patient had ever been offered admission to the first hospital, had refused admission to the first hospital, or requested transfer to the second hospital.

Interview with staff C on 9/15/10 at 12:25 PM revealed that, after she spoke with patient #2 and the patient's mother, she contacted the psychiatrist on call and the decision was made to transfer the patient to the other hospital for continuity of care, since the patient had previously been seen within the mental health system with which the second hospital was affiliated. Staff C stated that she spoke with the ED crisis evaluator at the second hospital, who, after speaking with a staff psychiatrist, called back and said the second hospital would not accept the patient due to staffing concerns; that the recommendation was made that the first hospital hold the patient in the ED and transfer her in the morning. Staff C stated she then spoke with the ED physician. She stated the patient had improved dramatically, so the physician made the decision that the mother could have the choice between taking the patient home or holding her in the ED and trying to transfer her. She was also given the option to return to the ED if the patient's symptoms returned.

Interview with staff D on 9/15/10 at 1:15 PM revealed that this individual was on call for psychiatry on 8/26/10. He had received a telephone call from staff C regarding patient #2. He stated there was a question regarding whether the patient needed to be admitted, and in such cases the options were to work out an alternative safety plan or to admit the patient. He stated he did not receive a return call from staff C, so he assumed that an alternative plan was worked out.

The medical record for patient #2 showed that at 11:30 PM the ED physician ordered the patient to be given Ativan 2 mg IM and then to discharge the patient. The ED nursing notes indicated the medication was given at 12:15 AM. The nurse charted the patient's condition as unchanged and the patient was discharged at 12:30 AM.

Interview with staff A on 9/14/10 at at 4:20 PM revealed that the hospital has an adult inpatient mental (MH) unit with a capacity of 18. At the time of this patient's visit to the ED, the census of the MH unit was eight patients.