HospitalInspections.org

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure patients were informed of their rights for 5 of 14 sample patients (#1, #2, #3, #4, #5). The findings were:

1. Medical record review for inpatients (#6 through #14) showed evidence the patients were offered information on patient rights. However, review of emergency department charts (#1, #2, #3, #4, #5) showed no evidence the patients or their representatives were given information on patient rights.

2. Review of the facility's policy "Patients' Rights and Responsibilities" (PolicyStat ID: 1030779, approved 09/2014) showed "...provides information on rights to each patient at the time of admission..." The policy failed to address informing patients in outpatient areas (including the emergency department) of their rights.

3. During an interview on 6/20/17 at 1:45 PM the regulatory director stated about a year ago they stopped using a form in the emergency department which would have shown patient rights information. He further verified there was no evidence currently that patients in the emergency department received information on patient rights.

Based on review of policies and procedures, review of emergency medical services (EMS) documentation, and staff and EMS personnel interviews, the facility failed to develop and/or implement policies related to emergency services. The findings were:

Review of EMS documentation showed on 6/7/17 an out-of-county ambulance crew contacted the emergency department (ED) by telephone. The crew told the ED they had a 15 year old with a self-induced overdose who was stable enough for transport to their facility. The documentation further showed 12 minutes later the crew received a phone call back from the ED who stated "sorry but due to patient being a pediatric psych patient, they do not have the means to care for patient." The documentation showed the patient was then taken to a nearby clinic and then was transported to a children's hospital via air ambulance. During an interview on 6/20/17 at 2:11 PM the paramedic involved in the case confirmed the ED staff told him they didn't have the ability to care for a pediatric psychiatric patient. On 6/20/17 at 11:30 AM the ED medical director, who was the ED physician working on 6/7/17, stated he never said he would not accept the patient. He stated he told EMS that they should take the patient to the nearest medical facility for medical stabilization because the patient was "intoxicated, altered." The following concerns related to policy development and implementation were identified:
a. Review of the facility's policy "Behavioral Health Care Treatment of Pediatric Patients" (PolicyStat ID 2982445, approved 12/2016) showed "However, due to the unavailability of behavioral health services for patients age thirteen and younger (herein referred to Pediatric Patient) at MHSC, the Hospital has developed a plan of behavioral health care for this specific patient population." According to the policy, a pediatric patient is defined as 13 years or younger; the patient involved in the case on 6/7/17 was 15 years old. During an interview on 6/21/17 at 1:19 PM, the nurse ED manager stated this was a current policy. When asked about pediatrics being defined as 13 years and younger, she stated that policy was written by the previous administration. She stated ED staff felt pediatrics was younger than 18 years old and they wanted to revise that policy. Further review of the policy showed it addressed what to do if a pediatric patient presented at the ED department with behavioral healthcare needs, but not what to do if an out-of-county ambulance called in to transport a pediatric patient with behavioral healthcare needs.
b. Review of ED policies showed the facility had an Emergency Medical and Treatment and Active Labor Act (EMTALA) policy which would apply to patients who arrived on hospital property, but did not have a policy to address communication with ambulances who were not on hospital property and wanted to transport a patient to the ED. During an interview on 6/20/17 at 3:34 PM the nurse ED manager stated the facility did not have a policy on communication with ambulances, nor a policy on which type of patients they would not accept because "...we accept all. We don't divert."