HospitalInspections.org

Based on review of records, policies/procedures, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide an appropriate medical screen exam (MSE) for 1 ED patient (Patient # 1) who presented to the ED with an emergency, out of 25 cases selected for review from June 2012 to November 2012. The CAH administrative staff identified an average of 250 emergency room visits per month.

Failure to provide an appropriate MSE within the CAH's capabilities for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the second medical record for Patient #1 revealed a 24 year old female presented to the Emergency Department (ED) on 9/29/12 at 7:05 pm with several lacerations to the left forearm. ED staff evaluated the patient and sutured the lacerations at the time of this visit. The medical record documented the patient had a history of cutting her left forearm about 1 week ago. The 9/29/12 medical record documented the patient felt a little anxious at this time, but had no suicidal ideation. ED staff discharged the patient back to the Residential Care Facility (RCF) with instructions to have the wounds reviewed in 10 days. The medical record documented that If they (RCF staff) wish, they could take the patient to have a higher level of psychiatric care, we are leaving that decision up to them. The patient indicated understanding and agreement with the plan. The ED provider did not document a psychiatric evaluation prior to discharging the patient.

2. Review of the first medical record for Patient #1 revealed a 24 year old female presented to the Emergency Department (ED) on 9/22/12 at 8:20 pm with lacerations to the left forearm. The medical record documented the ED staff evaluated the patient and sutured the lacerations at the time of this visit. Further, the patient had a long history of self mutilative behaviors and requested help for suicidal ideation. The ED staff transferred the patient to an inpatient psychiatric hospital after stabilizing the patient.

3. During an interview on 11/14/12 at 10:00 AM, Staff A, ER RN (registered nurse) stated Patient #1 presented to the ED with lacerations to the left forearm on 9/29/12. Staff provided treatment to the patient by cleansing and suturing the lacerations. The provider evaluated the patient's mental staus, but did not complete a psychiatric assessment to determine if patient at risk for further harm. ED staff transferred the patient back to the Residential Care Facility (RCF) and provided discharge instructions.

4. During an interview on 11/14/12 at 2:45 PM, Staff B, Physician's Assistant (PA) stated Patient #1 presented to the ED on 9/22/12 (earlier ED visit) with lacerations to left forearm and suicidal ideation. Staff provided treatment to the lacerations by cleansing and suturing them. After stabilizing the patient, staff transferred the patient to an inpatient psychiatric hospital for suicidal ideation on 9/22/12.

5. During an interview on 11/14/12 at 3:10 PM, Staff C, Advanced Registered Nurse Practitioner (ARNP) stated Patient #1 presented to the ED on 9/29/12 with lacerations to the left forearm. Staff provided treatment by cleansing and suturing the lacerations. The patient denied suicidal ideation, but complained of a little anxiety. The ED staff did discharge the patient back to the RCF with discharge instructions to have the wound evaluated in 10 days and If they wished the patient to have a higher level of psychiatric care, we (the ED) are leaving that decision up to the RCF staff.

Review of policy 687-3000, last reviewed and revised in 11/2012, titled, "Screening by Qualified Medical Personnel", revealed an Emergency Medical Screening Exam to rule out if an emergency medical condition exits (sp) will be done by a mid level provider or physician. The policy did not direct staff in providing a psychiatric medical screening examination to rule out an emergency psychiatric condition.

Review of the policy titled "Acceptance of a patient with an emergency medical condition", dated reviewed 4/20/10, revealed in part, "All patients presenting to Palmer Lutheran Health Center with an emergency medical condition which developed during transport to another hospital destination must be accepted and provided a medical sreening exam (MSE) and stabilizing treatment." The CAH did not have a policy for MSE of psychiatric patients.

The CAH ED staff failed to provide an appropriate MSE for a psychiatric patient to determine if an emergency medical condition existed within their capabilities including an appropriate transfer for Patient # 1.

Based on review of records, policies/procedures, and interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide a medical screening examination within the capabilities of the CAH for 1 ED patient (Patient # 1) who presented to the emergency room requesting care out of 25 cases selected for review from June 2012 to November 2012. The CAH administrative staff identified an average of 250 emergency room visits per month.

Failure to provide an appropriate medical screening examination (MSE) within the CAH's capabilities could potentially results in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. Review of the first medical record for Patient #1 revealed a 24 year old female presented to the Emergency Department (ED) on 9/22/12 with self inflicted deep lacerations to the left forearm with a piece of glass from a light bulb. ED staff evaluated the patient and sutured the lacerations at the time of this visit. The medical record documented the patient had a long history of self mutilative behaviors and requested help for suicidal ideation because of the recent death of a friend. The ED staff transferred the patient to an inpatient psychiatric hospital after stabilizing the patient.

2. Review of the second medical record for Patient #1 revealed a 24 year old female presented to the Emergency Department (ED) on 9/29/12 at 7:05 pm with seven lacerations to the left forearm. Patient #1 had several well healed scars and 1 healing, granulated wound. ED staff evaluated the patient and sutured the lacerations at the time of this visit. The medical record documented that the patient had cut her left forearm about 1 week ago and ED staff provided treatment at that time. The documentation revealed the patient stated she felt a little anxious at this time. The medical record lacked ED staff documentation of a psychiatric MSE to determine likelihood for further self harm. ED staff discharged the patient back to the Residential Care Facility (RCF) with instructions to have the wounds reviewed in 10 days and if they (RCF staff) wished the patient to have a higher level of psychiatric care, we (the ED) are leaving that decision up to them. The medical record documented the patient indicated understanding and agreement with the plan.

3. During an interview on 11/14/12 at 10:00 AM, Staff A, ER RN (registered nurse) stated Patient #1 presented to the ED with lacerations to the left forearm. Staff provided treatment to the patient by cleansing and suturing the lacerations. The provider evaluated the patient's mental staus and determined the patient not suicidal at that time. Staff transferred the patient back to the Residential Care Facility (RCF) with RCF staff and provided discharge instructions.

4. During an interview on 11/14/12 at 3:10 PM, Staff C, Advanced Registered Nurse Practitioner (ARNP) stated Patient #1 presented to the ED on 9/29/12 with lacerations to the left forearm. Staff provided treatment by cleansing and suturing the lacerations. The patient denied suicidal ideation, but complained of a little anxiety. The ED staff did discharge the patient back to the RCF with discharge instructions to have the wound evaluated in 10 days and if they (the RCF staff) wished the patient to have a higher level of psychiatric care, we are leaving that decision up to them.

5. During an interview on the afternoon of 11/14/12, the RCF Administrator reported Palmer Lutheran Hospital staff discharged the Patient on 9/29/12 to the RCF and told RCF staff, if they felt the Patient required a higher level of psychiatric care that was their decision. RCF staff disagreed with Palmer Lutheran staff about the level of psychiatric care required and called the psychiatric unit at Hospital B. Hospital B ' s psychiatric staff said to bring the Patient to Hospital B right away, they did, and Hospital B staff admitted the Patient.

According to hospital B ' s medical record, they admitted Patient #1 for psychiatric treatment, on 9/29/12 at 11:08 pm, related to trauma the Patient endured after a friend was beaten at the Patient ' s place of residence and later died, as well as, self-harm behaviors with suicidal ideation and a plan to commit suicide.

6. Review of policy 687-3000, last reviewed and revised in 11/2012, titled "Screening by Qualified Medical Personnel", revealed an Emergency Medical Screening Exam to rule out if an emergency medical condition exits (sp) will be done by a mid level provider or physician. The policy did not direct staff in providing a psychiatric medical screening examination to rule out an emergency psychiatric condition.

Review of the policy titled "Acceptance of a patient with an emergency medical condition", dated reviewed 4/20/10, revealed in part, "All patients presenting to Palmer Lutheran Health Center with an emergency medical condition which developed during transport to another hospital destination must be accepted and provided a medical sreen exam and stabilizing treatment." The CAH did not have a policy for MSE of psychiatric patients.

The CAH ED staff failed to provide an appropriate MSE for a psychiatric patient to determine if an emergency medical condition existed within their capabilities including an appropriate transfer for Patient # 1.