HospitalInspections.org

As directed by the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site allegation survey was conducted at this Facility from 10/24/17 through 10/26/17 to determine compliance with Emergency Medical Treatment And Labor Act (EMTALA) under the Responsibilities of Medicare Participating Hospitals in Emergency Cases, 42 CFR 489.20 and 42 CFR 489.24 for complaints
MO 00134690, and MO 00134637.

Review of the facility's ED policy titled "Involuntary Commitments (96 Hours)", last revised on 7/20/2015 reads in part, "Those with emergency medical conditions are stabilized prior to transfer to a psychiatric facility." "If stabilization is not possible within the Emergency Department, the patient is either admitted or appropriately transferred to another facility." The first (1.) "Procedure" staff should follow under the policy reads "Patients presenting with complaints or conditions suggestive of a psychiatric disturbance or condition shall receive a medical screening examination in the Emergency Department appropriate to the presenting complaint and sufficiently detailed to rule out the presence of trauma, medical or effects of drugs or toxins that might cause the symptoms or conditions observed or which might co-exist with the observed disturbance.

The facility failed to follow its policy and procedure and did not provide a medical screening examination (MSE) within its capabilities and capacity to one individual (Patient #23) who presented to the emergency department (ED) seeking care.

Review of patient # 23's medical record showed the patient presented to the ED on 4/8/17 at 6:58 p.m. seeking care following a "suicide attempt." The ED triage nurse documented the patient's triage status as "Urgent", that she placed patient # 23 in ED room 2 and that the patient was yelling and cussing at family present in the room. Further documentation showed patient # 23 was anxious, had a history of inpatient treatment at a psychiatric hospital, and had a shoestring tied around his neck and stated that he was going to kill himself - hang himself from a tree. The ED triage nurse documented that patient # 23 left the ED at 7:13 p.m. without being seen by the ED physician.

Refer to tag A 2406 for details.

The facility failed to follow its policy and procedure and did not provide two individuals (patient # 20 and 24) who presented to the ED seeking care for their emergency with further examination and stabilizing treatment.

Review of patient # 20's medical record showed the patient presented to the ED accompanied by her primary care provider (PCP) seeking care for a psychiatric emergency on 10/19/17 at 1:50 p.m. The ED triage nurse documented patient # 20 was "Emergent", and the PCP completed an affidavit to support a 96 hour hold (involuntary commitment). Review of the affidavit showed the PCP documented that patient # 20 was depressed, crying, and thinking about suicide constantly, and that she had researched on the internet several plans for suicide but would not disclose the plans. At 5:10 p.m. a psychiatric crisis worker determined patient # 20 was safe for discharge. Further documentation showed the patient's spouse would place all knives in a locked place and stay with the patient in the event she became depressed again and that the patient would follow up with psychiatry in the morning for a formal psychiatric evaluation for possible medication adjustment. The patient left the ED at 5:19 p.m.

Review of patient # 24's medical record showed the patient presented to the ED on 9/9/17 at 5:12 p.m. complaining of suicidal thoughts for the past several days with a plan to hang himself. Further documentation showed that the patient reported he attempted to hang himself two days prior, but was stopped by a friend. The ED physician determined the patient had an emergency medical condition and required transfer to a hospital with psychiatric capabilities. The ED staff attempted to locate an accepting hospital without success. Under the assumption a 96 hour involuntary commitment would facilitate transfer to a hospital with psychiatric capabilities, the ED physician contacted law enforcement for assistance in obtaining the 96 hour hold. Law enforcement came to the ED and determined the patient had an outstanding warrant. The patient was arrested and taken to jail prior to receiving treatment to stabilize his emergency medical condition.

Refer to tag A 2407 for details.

Based on interview, review of Emergency Department (ED) logs, Medical Records, and Policy review the Facility failed to provide within its capabilities and capacity, a medical screening examination (MSE) sufficient to determine whtether or not an emergency medical condition (EMC) within for one patient (#23) of 24 ED records reviewed from April 2017 through October 2017. This failure had the potential to effect all patients that presented to this hospital's ED. The Emergency Department (ED) reported seeing approximately 368 psychiatric patients per year. The ED had seen in total, approximately 4,732 patients per year. The Facility's census was three at the time of the survey.

Findings included:

Review of the Facility's policy titled, "Emergency Medical Treatment and Active labor Act (EMTALA)," revised 04/2015, showed the directives for staff to perform a MSE:

- The facility has a responsibility to provide any individual presenting to the facility (including premises of the main hospital facility) with an appropriate medical screening examination within the scope of the institution's capability and capacity, including ancillary services routinely available.

- The term "Emergency Medical Condition" means a medical condition manifesting itself as acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to jeopardize the health of the individual.

- The term "to stabilize" means to provide such medical treatment of the condition, as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition was likely result from or occur during the transfer of the individual from the facility.

Review of the Facility's policy titled, "Involuntary commitment (96 Hours)," revised 07/20/15, showed the directives for staff to ensure all patients presenting to the ED with complaints or conditions suggestive of a psychiatric disturbance or condition to receive a Medical Screening Examination in the ED appropriate to the presenting complaint and sufficiently detailed to rule out the presence of trauma, medical or effects of drugs or toxins that might cause the symptoms or conditions observed or which might co-exist with the observed disturbance. At the physician's orders, Behavioral Health will be called to assess the patient and find appropriate transfer disposition.

Review of the Facility's policy titled, "Management of the Severely Depressed/Suicidal Patient," revised 09/2017, showed the directives for staff to provide a safe environment until the patient becomes medically stable:

- Provide a staff member who can monitor patient one to one;
- Get assistance from other professionals; and
- Act definitively-tell the patient what you want him/her to do and what actions you were going to take.

Review of Patient #23 medical record from the ED, on 04/08/17, showed the following:
- At 6:58 PM, a 27 year old male presented to the ED following a suicide attempt;
- Pre-hospital intervention showed "none";
- The nurse's notes showed that patient #23 had a "shoestring tied around his neck and stated that he was going to kill himself by hanging himself with the shoestring from a tree";
- At 7:09 PM, the patient was placed in treatment room #2;
- At 7:19 PM, the mother entered the treatment room #2, the patient and the mother started "cussing" at each other;
- The patient got up from the bed and "stormed out" of the ED and refused to stop or stay;
- The ED physician did not examine the patient; and
- Addendum added at 7:35 PM documented that the patient admitted to drinking four "beers" as well as half a can of "14 percent alcohol" and smoking "pot."

During an interview on 10/25/17 at 2:20 PM, Registered Nurse (RN) K, stated that:
- She was present in the Emergency Department on 04/08/17;
- She remembered that Patient #23 presented to the ED with a complaint of suicide attempt by trying to hang himself with a shoestring, and still had the shoestring tied around his neck;
- She escorted the patient to treatment room #2
- She let the mother into treatment room #2 to "calm the patient and help watch him";
- The mother and patient started "cussing" at each other;
- The patient the left the ED;
- She did not initiate suicidal precautions;
- There was no order for restraints, so she could not restrain the patient from leaving;
- She could have initiated an 96 hour hold, but did not attempt to do so; and
- She had not notified the ED physician, and the physician did not see the patient.

During an interview on 10/25/17 at 2:50 PM, RN J, stated that:
- He remembered Patient #23 and the events on 04/08/17;
- We have a "no hands on policy", that was why we did not try to stop the patient from leaving;
- He never initiated suicidal precautions; and
- He did not initiated a 96 hour hold,

During an interview on 10/26/17 at 9:15 AM, the hospital's Chief Medical Director stated if a patient was at risk of harming themselves or others, it was the facility's responsibility to protect that patient, and immediately initiate Suicidal Precautions. If a patient was on hospital grounds and requested to have an exam by a physician, it was the facility's responsibility that a physician would examine the patient.

The medical record did not contain evidence that patient # 23 received a medical screening exam, or that staff initiated precautions to ensure the patient remained safe, or attempted to de-escalate the patient when he became verbally aggessive. These oversights allowed the patient to leave the facility unsupervised, and in an unsafe condition which had the potential to cause further injury or death.

Based on interview, review of Emergency Department (ED) logs, Medical Records, and Policy review, the hospital failed to stabilize and/or arrange an appropriate transfer within the hospital's capacity and capability of two patients (#24 and #20) with an Emergency Medical Condition (EMC), out of 24 patient records reviewed between April 2017 through October 2017. The Facility reported it had seen approximately 368 psychiatric patients per year. The ED reported it had seen in total, approximately 4,732 patients per year. The hospital's census at the time of survey was three.

Findings included:

Review of the Facility's policy titled, "Emergency Medical Treatment and Active labor Act (EMTALA)," revised 04/2015, showed the directives for staff to perform a Medical Screening Exam (MSE):

- The term "Emergency Medical Condition" means a medical condition manifesting itself as acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to jeopardize the health of the individual.

- The term "to stabilize" means to provide such medical treatment of the condition, as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition is likely result from or occur during the transfer of the individual from the facility.

- A patient with an unstable emergency medical condition may be appropriately transferred if the medical benefits reasonably expected from the provision of the appropriate medical care at another facility.

Review of the Facility's policy titled, "Involuntary commitment (96 Hours)," revised 07/20/15, showed the directives for staff to ensure all patients to be transferred for involuntary evaluation pursuant to Missouri State Law, due to the determination of the physician that the patient is a danger to self or others, the transfer procedures, including physician certificate for transfer, informed consent of the patient or legal guardian and transfer information sheets were completed. At the physician's orders, Behavioral Health would be called to assess patient and find appropriate transfer disposition.

Review of Patient #24 medical record from the ED, on 09/09/17, showed the following:

- At 5:12 AM, Patient #24, a 40 year old male arrived at the facility via private vehicle with chief complaint of Suicidal Thoughts;
- The patient reported he had an unstable social situation, a recent job loss, that increased his thoughts of suicide;
- That he had a plan to "hang himself" which he attempted two days prior that was stopped by a friend;
- At 6:01 AM, the ED physician examined the patient and documented the patient had suicidal thoughts;
- At 6:55 AM, laboratory tests were ordered;
- At 8:15 AM, Psychiatric assessment was completed and an attempt to find inpatient psychiatric treatment was initiated without success;
- At 5:25 PM, ED Physician A requested Law Enforcement to "evaluate the patient";
- At 5:52 PM, Law Enforcement discovered that the patient had a "warrant" and arrested the patient;
- At 6:00 PM, staff canceled transfer plans; and
- The ED physician discharged the patient to Law Enforcement for transport to jail.

During an interview on 10/25/17 at 3:15 PM, Registered Nurse (RN) B stated that:

- She remembered Patient #24 and the events on 09/09/17;
- Patient #24 had suicidal thoughts with a plan to hang himself;
- The patient had attempted to hang himself prior to admission to the ED;
- Behavioral Health had attempted to find inpatient placement and was unsuccessful;
- ED Physician A told her that if Law Enforcement signed an Affidavit for a 96 hour hold (application used by facilities to involuntarily hold a patient at risk for imminent harm to self or others) finding placement for inpatient psychiatric treatment would be easier;
- Law Enforcement arrived, and detained the patient, took Patient #24 from the ED;
- She could have signed an Affidavit for 96 hour hold;
- The ED Physician or Behavioral health staff never re-evaluated the patient; and
- She did not provide Patient #24 with any discharge and/or follow up instructions.

During an interview on 10/25/17 at 4:10 PM, ED Physician A stated that:

- He remembered Patient #24 and the events on 09/09/17;
- He called Law Enforcement to write an Affidavit for a 96 hour hold to help facilitate inpatient psychiatric placement;
- When Law Enforcement arrived, ED physician A told them that the facility was having trouble finding inpatient placement;
- Law Enforcement detained Patient #24, and exited the ED;
- Patient #24 was not fit for confinement (medically safe to be detained);
- Patient #24 needed psychiatric inpatient care and evaluation by a Psychiatrist; and
- He did not write any orders for suicidal precautions and/ or follow up with a Psychiatrist.

During a telephone interview on 10/26/17 at 4:15 PM, Law Enforcement Officer, stated that:

- The ED Physician called for an Affidavit to be signed for a patient;
- After talking with Patient #24, he detained the patient, related to an outstanding warrant;
- The ED Physician never discussed with him whether Patient #24 was fit for confinement;
- In the Detention Center patient # 24 did not have medical access, or access to a Physician; and
- If an offender was suicidal, the detention center provided no constant observation to prevent injury.

During an interview on 10/26/17 at 9:30 AM, the hospital's Chief Nursing Officer, stated that:

- There were no reasons to call Law Enforcement for an Affidavit;
- The ED Staff were capable of initiating a 96 hour Hold, and
- We could have admitted the patient to the floor on an "Extended ED Stay" with a constant observer.

During an interview on 10/26/17 at 9:15 AM, the hospital's Chief Medical Director stated that the facility had the capability to hold a patient on 96 hour hold. A Detention Center was not an appropriate facility for a patient that required inpatient psychiatric treatment.

The evidence in the medical record showed that patient # 24 did not receive stabilizing treatment for his emergency prior to discharge to law enforcement. This facility had the capacity and capability to provide further examination and treatment, including arranging an appropriate transfer to a hospital with psychiatric capabilities to stabilize patient # 24's psychiatric emergency.

Review of Patient #20's ED medical record on 10/19/17, showed:

- At 1:30 PM, Patient #20, a 25 year old female, arrived at the facility accompanied by her Primary Care Provider (PCP) with a chief complaint of suicidal thoughts;
- Documentation showed the patient had history of depression, and was currently taking medication to control her depression;
- At 2:49 ED Physician C examined patient # 20;
- At 2:44 PM, the PCP completed an Affidavit to support a 96 hour hold (involuntary hold of a person who was an imminent danger to self or others);
- At 3:25 PM, the patient requested to leave and the physician advised the patient that she could not;
- At 5:10 PM, psychiatric evaluation was performed;
- At 5:18 PM, Patient #20 was discharged home; and
- At 6:27 PM, ED physician C noted that he felt patient # 20 was safe for discharge, and instructed the patient follow up as an outpatient.

Review of the Affidavit for Involuntary Commitment for a 96 Hours hold, dated 10/19/17, signed by the PCP, showed:

- Patient #20 presented to the PCP's clinic depressed, crying, and stated she had been thinking about suicide constantly, increasing over the past week;
- She had researched suicide on the Internet, had several plans, but would not disclose them;
- She did not think she could resist the urge to commit suicide any longer; and
- The current medication she had taken was not effective.

Reeview of the ED physician's documented physical exam dated 10/19/17 at 2:49 PM, showed:

- Patient #20 presented to the ED accompanied by her PCP with a report of suicidal thoughts;
- She became overwhelmed about things in her life;
- She had been looking up topics about suicide on the Internet; and
- She was not serious about actually committing suicide.

Review of the ED psychiatric evaluation dated 10/19/17 at 5:03 PM, showed:

- Patient #20 admitted having suicidal ideation periodically;
- She admitted to reading about suicide on the internet which caused "unusual strong feelings" that frightened her;
- She immediately sought help from her husband and family;
- There were several methods from the Internet, but she had no plan and/or desire to harm herself;
- She agreed to keep herself safe, and to work with her husband and family until morning;
- She agreed to follow up as an outpatient to begin psychiatric treatment and therapy;
- Discharged Patient #20 to the care of her husband, with
- Instructions to remove all dangerous items from the patient's access.

Review of the ED nurses' notes dated 10/19/17 at 5:11 PM, showed:

- The crisis worker felt that Patient #20 was not a danger to herself or others at this time;
- The crisis worker felt that Patient #20 was safe to go home with a safety plan in place; and
- Patient#20's husband would place all knives in a locked place, and stay with the patient in the event she became depressed again.

Review of the ED treatment/ management plan dated 10/19/17 at 6:27 PM, showed:

- Patient #20 admitted to thoughts of suicide earlier, but denied any seriousness of doing so;
- The patient stated "I have too much to live for";
- The patient was to follow up in the morning for further evaluation; and
- ED physician C felt the patient was safe for discharge.

Review of the ED disposition dated 10/19/17 at 5:19 PM, showed:

- The patient was to follow up with psychiatry in the morning for a formal psychiatric evaluation for possible medication adjustment; and
- The husband told the nurse he would stay with the patient all night and ensure that the patient would follow up with psychiatry in the morning.

During an interview on 10/26/17 at 9:25 AM, ED Physician C stated that:

- He remembered Patient #20 and the events on 10/19/17;
- He never spoke with the PCP that presented with the patient;
- The evaluation of the patient showed she had suicidal thoughts;
- The patient had searched the internet on suicide;
- The search scared her, so she requested help;
- The patient had intermittent thoughts of suicide;
- Physician C never arranged for transfer to an inpatient psychiatric facility; and
- Physician C thought the patient was safe for discharge home on a safety plan with follow up with psychiatry for further treatment.

During an interview on 10/26/17 at 9:15 AM, the hospital's Chief Medical Director stated that the facility had the capability to hold a patient on 96 hour hold. If a patient was at risk of harming themselves or others, it was the facility's responsibility to protect that patient.