HospitalInspections.org

Based on record review and interview, the facility failed to ensure appropriate medical screening for 1 (Pt #5) of 23 records reviewed of patients coming to the ED for sreening and treatment for an acute condition. This failed practice had the potential to impact all ED patients by delaying needed and life-saving interventions.

See finding under tag 2406.


41505

Based on record review and interview, the facility failed to ensure appropriate psychiatric screen was conducted for patients presenting to the ED (with a medical history of psychiatric disorders) for 1 (Pt #5 ) of 23 records reviewed.

Findings

Pt #5
On a document titled, "ED triage notes," DO #1 documented Pt #5 presented to the ED department on 05/28/24 at 2:35 am with chief complaints of anxiety.

On a triage noted dated 05/28/24 at 2:39 am, RN #3 documented, "Patient states a man is harrassing her and she has reported it to the police so she is stressing out, has anxiety, doesn't want to eat states she just wants to hide."

On a document titled, "Patient Care Timeline" dated 05/28/24 at 2:41 am, RN #3 documented vital signs for Pt #5 upon admission as: Temperature 97.3 Farenheit, 95 pulse, 18 respiration, 155/102 blood pressure, and 95% oxygen saturation. Documentation showed no further screening related to anxiety and no further screening regarding the elevated blood pressure.

On a document titled, "Initial Triage Screening" dated 05/28/42 at 0242 am, RN #3 documented
"no" to patient having any signs/symptoms or history of opioid abuse/misue or suicide risks.

On a doucment titled, "Patient Care Timeline" dated 05/28/24 at 2:43 am, RN #2 documented in answer to "Abuse Indicators and "Abuse/Neglect Screening" Pt #5 was alone and that she felt safe at home.

On a document titled, "Patient Care Timeline" (dated 05/28/24 at 4:03 am), RN # 2 documented Pt #5 walked out of the trauma room holding her emisis bag filled of clear liquids stating, "I am scared. I need someone in my rooom with me. I can't be alone." RN # 2 documented the patient was asked to go back to her room and they would let their charge nurse know.

An ED provider note completed by DO #1 on 05/28/24 at 5:16 am documented a past medical history for Pt #5 as alcohol abuse, drug abuse, mitral valve prolapse, peptic ulcer and seizures with report from patient that last seizure occured three months ago (grand mal seizure) while hospitalized. Documentation showed a problem list (as of 05/28/24) of depressive disorder, history of suicide attempt, intractable vomitting, nausea & vomiting, palpitations, PTSD sexual assault, suicidal deliberate poisoning, suicidal ideation, and unspecified mood affective disorder.

On an ED provider note dated 05/28/24 (filed at 5:19 am) DO #1 documented Pt #5 presented to ER stating:
1. she was being stalked which was already reported to police;
2. she was vomitting continuously (unverified by facility). Facility documented patient would not vomit into the emisis bag in the room but would go to restroom, where water could be heard running in sink and patient would return with a bag of vomit which was clear with no particulate matter.

On a document titled, "discharge form" dated 05/28/24 at 6:03 am, AT #2 left the following two items unanswered (blank):
1. Understanding of instructions verbalized by patient or responsible adult and
2. Responsible adult present for escort.

On a document titled, Patient Care Timeline dated 05/28/24 at 04:56 am, RN #2 documented Pt #5 was
cooperative, tearful, sad, and had a flat affect.

On an ED Disposition note dated 05/28/24 at 5:12 am, DO #1 documented condition of Patient #5 at discharge was, "improved."

On an ED provider note (dated 05/28/24 at 05:19 am) DO #1 documented, "Feel that patient very likely needs to be followed up with (name omitted - a psychiatric hospital) and that patient stated that she is living with her parents right now but she then in the same breath will say that she is afraid of being alone and if she goes home she will be alone....Will discharge her to home...I have advised that she would follow-up with (proper name omitted) at her other mental health counselors."

On an ED Disposition note dated 05/28/24 at 0539, DO #1 documented the disposition for Patient #5 as "Home or Self Care."

Documentation showed no reassessment of initial blood pressure of 155/102 during her ED visit and no psychiatric or behavioral health assessment completed to evaluate the patient's complaints (vomitting, being stalked, concerns with being alone and anxiety).

During an interview with the Quality Manager on 06/25/24 at 11:30 am, she sated, "yes"when asked if ED records were reviewed for EMTALA requirements.