HospitalInspections.org

Based on interview and review of emergency department medical records, it was determined that the hospital did not comply with the provider agreement as defined in 42 CFR 489.24(b), to comply with 42 CFR 489.24.

Findings include:

1. The hospital failed to maintain a central log of each individual who came to the emergency department seeking assistance. (Refer to tag A-2405)

2. The hospital failed to provide an appropriate medical screening examination. (Refer to tag A-2406)

Based on interview and record review it was determined that the hospital failed to maintain a central log of each individual who came to the emergency department seeking assistance. Specifically, 1 of 21 sample patients who came to the ED seeking assistance was not placed on the hospital's central log. (Patient identifier 21.)

Findings include:

A complaint was called in regarding patient 21 and the lack of care she received, when she was brought to the hospital's ED on 10/16/19.

1. On 10/23/19 the central log for the date the allegation occurred was reviewed and the patient's name was not found. The central log was reviewed for the days immediately prior to and after the date provided by the complainant. The hospital's electronic medical record system was also accessed and the patient's name was placed in the search bar, the patient's name was not found.

2. After interviews with hospital staff, a local police officer, and a family member of patient 21 were completed, it was determined patient 21's family had sought treatment for patient 21 at the hospital's ED on 10/16/19. (Refer to tag A-2406).

3. On 10/24/19 an interview was conducted with the hospital's chief nursing officer (CNO). The CNO confirmed patient 21 should have been placed on the hospital's central log.

Based on interview and record review it was determined that the hospital failed to provide an appropriate medical screening examination for one sample patient to determine if an emergency medical condition existed. Twenty medical records were reviewed, however, none of the 20 medical records included the complaint patient because the hospital failed to list the patient on the central log, evaluate the patient, or create a medical record for the patient, therefore there was no record to review. (Patient identifier 21.)

Findings include:

A complaint was received regarding patient 21 and the lack of care she received, when she was brought to the hospital's Emergency Department (ED) on 10/16/19. The complainant indicated the local police were also involved.

1. On 10/23/19, the central log for the date the allegation occurred was reviewed and the patient's name was not found. The central log was reviewed for the days immediately prior to and after the date provided by the complainant. The hospital's electronic medical record system was also accessed and the patient's name was placed in the search bar - the patient's name was not found.

No medical record review could be conducted because the hospital had no record of the patient ever coming to the hospital

2. On 10/23/19, at 10:51 AM, the hospital quality assurance (QA) manager was interviewed and informed survey staff that, if police were called to the ED, security would have an incident report.

The hospital's security incident log, for October 2019, was reviewed. This revealed one incident on 10/16/19 (the date which the complainant alleged patient 21 was turned away from the ED.) No names of any of individuals who were present in the ED during the incident, besides the hospital's security officer, were on the report.

The security incident report, from 10/16/19, revealed the security officer received a call, " ...to come to the waiting room of the emergency department. Upon arriving there was a (sic) two ladies and two men in the waiting room. They were trying to hold down what seemed to be a very intoxicated female in the chair. They said she needed to be admitted and they could not handle her anymore. She was compliant as I talked to her and stated all she wanted to do was go home. About 1915 (7:15 PM) or so 3 Bountiful Police Officers showed (sic) to talk with the family. After about 45 minutes of talking with the female and the family separately they stated they had no reason to pink sheet (an emergency application for involuntary commitment without certification form completed by a peace officer or Mental Health Officer requesting temporary commitment of a person) her or keep her. They left the hospital about 2000 (8:00 PM). The family remained and tried to talk the female into self admitting herself (sic) into the hospital for observation and to get some help they believed she needed. The scene was calm when I got a call to go to another floor. I told the PBX operator to call if there were any further issues."

On 10/23/19 at 11:49 AM, a review and interview of the 10/16/19 incident, in the hospital ED, was completed with the hospital's security manager and the security officer who responded. The security officer who responded to the incident stated he was called to the ED on 10/16/19 to help with an "intoxicated lady". The security officer stated, when he arrived at the ED, a woman was being physically held down by her mother in the ED waiting area. The officer stated the woman being held down was brought to the ED by her mother, her husband, and her husband's father. The officer stated he talked with the woman's husband who stated they did not know what else to do and that the woman had "torn up their home." The officer stated he talked with the woman being held down, and that she was "calm" and informed him she just wanted to go home. The officer stated he talked with "the admitting people" and they told him that "we can't help her unless she self admits." The officer stated that, by the time the local police arrived and "they took the intoxicated woman into the consultation room," they talked to patient 21 for about "40 minutes, maybe close to an hour." The officer stated the police officers told him "there was nothing they could do" and that he got a call to another floor and by the time he made it back to the ED they had left.

Interviews were conducted with patient 21's mother and the local police officer who were both present during the incident above and both confirmed this incident was with the patient named in the complaint, patient 21.

3. On 10/23/19 at 10:59 AM, a telephone interview was conducted with the mother of patient 21 to ask if she was present when her daughter was brought to the ED on 10/16/19. Patient 21's mother confirmed she was present and that she, her daughter's husband and her daughter's, husband's father, brought patient 21 to the ED. Patient 21's mother stated she entered the ED and told the clerk that they needed assistance getting her daughter into the ED from her car. Patient 21's mother stated she had parked her car "right outside the sliding glass doors." Patient 21's mother stated the ED clerk informed her they could not help bring her daughter into the ED from the car. Patient 21's mother stated her daughter's husband and her husband's father had to physically bring her daughter into the ED. Patient 21's mother stated she told the ED clerk that they had brought her daughter in to the ED because she had threatened to jump off of her balcony and that she "wanted to go back to her lord god." Patient 21's mother further stated her daughter had broken glass all over her house and that she had children in the house. Patient 21's mother stated the ED clerk stated they could not help her daughter and that she should call the police who may be able to help. Patient 21's mother stated she called 911 on her cell phone and that initially two police officers arrived, with a third arriving shortly after the first two. Patient 21's mother stated the police officers took her daughter to a room just to the side of the clerk's desk and talked with her separately. Patient 21's mother stated they told the police officers of her daughter's threat to kill herself and even showed the officers pictures of the house. Patient 21's mother stated the police officers then told her that they could not see any reason to keep her daughter, "and they turned us loose." Patient 21's mother further sated the next day her daughter stated, "She was going to OD (overdose)" and "she was going to sleep and her lord god." Patient 21's mother stated that 911 was called and the police took her daughter to another hospital where she was admitted to their psychiatric unit for five days. Patient 21's mother then stated, "We were not treated like we were at a medical facility. I mean if anyone even examined her they would have known things were out of whack." Patient 21's mother further stated, "I am so upset that we came to the emergency department and got absolutely no help. I mean we could have had a death. We had an absolute crisis on our hands and got absolutely no help at Lakeview emergency room." Patient 21's mother confirmed no medical personnel from the hospital saw her daughter while they were in the ED.

4. On 10/23/19 at 2:48 PM, an interview was conducted with the ED registrar who was working on 10/16/19. Also present during the interview were the hospital's chief nursing officer (CNO), QA manger, and the registrar's supervisor. The registrar stated the patient's mother walked in to the ED and stated she needed help out front to get her daughter inside. The registrar stated she asked the mother what the issue was and she stated, "She has been drinking and is having SI (suicidal ideation) issues," but that she did not want to come into the ED. The registrar stated she told the mother that "unfortunately we can't force them to be seen if they are over 18." The registrar stated she called one of the registered nurses (RN's) to confirm what she had told the mother was correct and the RN told the registrar, "There is nothing we can do, we can't force them to be seen." The registrar stated she told the mother the RN confirmed they could not "force" her daughter to be seen, but that she could call security, who also could not force her in, and at the same time she saw the husband "bear hugging" and carrying the patient into the ED. The registrar stated she did inform the mother she could call the police. The registrar stated the police arrived "shortly" after the patient had been carried into the ED. The registrar confirmed no medical personnel from the hospital saw the patient. The hospital CNO stated she talked with the ED manager and confirmed with him that the hospital staff could not force anyone into the ED unless the police stated to. The CNO further stated the ED manager told her, "You can't go out and screen in the lobby."

5. On 10/23/19 at 3:46 PM, an interview was conducted with the hospital CNO and QA manger. The CNO confirmed no medical personnel approached the woman discussed in the 10/16/19 security incident report.

6. On 10/23/19 at 4:14 PM, a telephone interview was conducted with the local police officer who responded to the incident in the ED on 10/16/19. The officer stated he arrived at Lakeview hospital's ED waiting room, where patient 21 had been brought by her husband, mother, and her husband's father. The officer stated patient 21's family brought her in to the ED for a, "mental eval." The officer stated, when he arrived, patient 21 was in the ED's consultation room and family stated she had told them that she "wants to return home to her heavenly father and her god." The officer stated patient 21's husband did show him a video of patient 21 breaking things in the house. The officer stated he spoke with patient 21 in the consultation room and that she stated she did not want to hurt herself and she did not want to die. The officer stated he informed patient 21's husband and mother that "our part is done." The officer stated, when he left the hospital, patient 21 was still in the consultation room in the ED. The officer stated he did not see a medical professional speak with patient 21 while he was at the hospital.

The police report correlating with the hospital security incident, dated 10/16/19, was reviewed. The report, dated 10/16/19 at 7:12 PM, revealed the officer responded to Lakeview hospital's ED at the request of patient 21's husband who had taken his wife to the ED for a "mental evaluation," and that he was, "requesting officers pink sheet" patient 21. The report also revealed, " ...(name of patient 21's husband) said (name of patient 21) did not want to be there but they felt she needed assistance ...on Monday night, (name of patient 21) broke items in their residence. (Name of patient 21's husband) did show me a video of the damage he took with his cell phone. (The name of patient 21's husband) said he believes (name of patient 21) is suicidal and (name of patient 21) said she wants to return to her 'Lord God'.

I (police officer) made contact with (name of patient 21). (Name of patient 21) said she and her husband are in the process of getting divorced. (Name of patient 21) said she did break a few items in her house and the items were hers. (Name of patient 21) said no one else was home when she broke the items. (Name of patient 21) said she did not want to be here at Lakeview and her family forced her into the van at her residence in (name of local city) and dragged her into the hospital.

I (police officer) told (name of patient 21) her family was concerned about her well being and that she was making threats of suicide. I (police officer) asked (name of patient 21) is (sic) she wanted to die, (name of patient 21) said no. I (police officer) asked (name of patient 21) if she wanted to hurt anyone and (name of patient 21) said no. (Name of patient 21) said she does not want to die and does not want to hurt anyone. (Name of patient 21) said she has three children that need her and she wants to be there for them. (Name of patient 21) said she does use medication for anxiety and for depression. (Name of patient 21) said she wanted to go home and sleep. I (police officer) asked (name of patient 21) if she wanted to be seen by a doctor as her family was requesting. (Name of patient 21) said she did not want to be seen and she felt fine.

...(Name of patient 21's husband) said he did not want to get her into trouble but wanted her to get help. I (police officer) informed (name of patient 21's husband) that (name of patient 21) provided me with no indication that she would self harm herself or to others based on this information, no further action would be taken ..."

7. On 10/23/19 at 4:20 PM, an interview was conducted with the hospital CNO and QA manager. The CNO stated she had contacted corporate and they informed her that the hospital should have screened the patient who came into the ED on 10/16/19.

8. On 10/24/19, a review of the medical record from the hospital where Patient 21 was admitted on 10/17/19 at 1:11 PM, due to an overdose, was completed.

Note: Patient 21 overdosed less than 24 hours after being turned away from Lakeview Hospital on 10/16/19.

9. A review of the admitting hospital's emergency room physician documentation, dated 10/17/19 at 1:36 PM, revealed the following:

Patient 21, " ...presents (sic) emergency department with suicidal ideation and following a (sic) overdose. Patient overdosed on lorazepam and Ambien as well as alcohol. She had been texting with her mother who ultimately called police who then found the patient laying in her bed at home. Patient was conscious but did report multiple times that she wanted to go to sleep without waking up ..." The physician noted the crisis team was alerted and arrived to evaluate patient 21. The crisis worker informed the physician that patient 21 had made "multiple statements to family members that she wants to simply go 'home' and by this she means to heaven." The crisis worker also informed the physician that patient 21's husband, " ...found his children at home with her intoxicated multiple times with broken glass throughout the house. He did attempt to find help earlier this week but was told there was little if (sic) they were able to do via police."

10. A review of the admitting hospital's crisis worker's (CW) behavioral health notes, dated 10/17/19, revealed the following:

"(Name of patient 21) was not the most accurate reported and CW had to talk to husband to get the most accurate information. (Name of patient 21) would answer questions but was very guarded. (Name of patient 21) is a heavy alcoholic and with her OD she is currently a danger to herself and her 2 kids at home. (Name of patient 21) is also going through marital problems with husband saying they may get divorced and although (name of patient 21) denies feeling suicidal, she overdosed and reported to her husband that she wants to go to bed and never wake up. CW staffed with Dr. (name of physician) and CW agree that (name of patient 21) needs immediate inpatient stabilization for her and her children's sake." The notes also revealed, "(name of patient 21) is currently a danger to her self (sic) and her kids ..."

11. A review of the admitting hospital's nursing documentation, dated 10/17/19, revealed the following:

" ...Pt (patient) lives with her husband and three children 12yr (years), 8yr, 8mos (months). Pt reports that she intentionally took an unknown quantity of her prescribed Ambien 10mg (milligrams) and Ativan 2mg. pt stated she wanted 'go to sleep and not wake up.' Husband reports that she has been heavily drinking daily and making suicidal statements at home lately ..."