HospitalInspections.org

Based on medical record review, review of hospital policy, review of hospital documentation, review of a security video and interviews for one of twenty-five patients (Patient #1) reviewed for emergency care and treatment, the hospital failed to ensure that the patient was evaluated by the physician prior to transfer. The finding includes:

Patient #1 had a history of chronic psychosis, schizoaffective disorder and bipolar disorder. P #1's medical record dated 1/25/21 identified arrived as a walk-in to the satellite ED (emergency department) with a chief complaint of neck and back pain and left without being seen (LWBS) forty- one minutes after arrival.

An unauthenticated note (by RN #1) in P #1's medical record, undated and untimed, noted P #1 was not triaged or evaluated by the MD.

The PEER dated 1/25/21 noted that P #1 took off his/her pants in the lobby and was acting disoriented, suspicious, and agitated, had racing thoughts and was rambling. P #1 was transported to Hospital #1's Main ED in another city from the Hospital satellite ED waiting room on 1/25/21.

The ambulance run sheet dated 1/25/21 indicated that P #1 was in the lobby of the satellite ED, was not acting properly, had altered mental status and the local PD (police department) completed a PEER (police emergency evaluation request).

The security video dated 1/25/21 was reviewed on 2/4/21 at 11:40 AM and identified the following, 1. P #1 was disheveled, entered the ED pushing the vestibule W/C (wheelchair) and sat in both the waiting room chair and the W/C. 2. RN #1 entered the waiting area with a medical mask on, extended a medical mask to P #1 and placed the mask on P #1's chest when P #1 did not take the mask. 3. SO (security officer) #1 entered the waiting room through the ED treatment area door and stayed with P #1 as P #1 held his/her own ears, sat in different ED chairs, walked around and removed his/her own pants, boots and socks. 4. A local and state police officer arrived and a team of four emergency responders arrived in the waiting area. 5. P #1 put his/her pants back on, positioned him/herself on the ambulance stretcher without assistance and was wheeled out of the ED. 6. RN #1 did not return to P #1 to perform an assessment. 7. MD #1 did not enter the waiting room to assess P #1.

An email from MD #1 to MD #3 (ED Chair/Chief) dated 1/25/21 at 11:53 PM identified that MD #1 did not evaluate or see P #1 and asked for police to be called.

Interview with RN #1 on 2/4/21 at 10:11 AM noted that, on 1/25/21, P #1 was yelling loudly, was not making sense and placed a medical mask on P #1's chest because P #1 was not following directions. RN #1 further identified that she had SO #1 go to P #1 and police were called per MD #1's direction.

Interview with MD #1 on 2/4/21 at 11:11 AM indicated that RN #1 told her that she didn't feel safe to triage P #1, P #1 refused to wear a mask and RN #1 said she was not going to get herself or her family sick. MD #1 further noted that SO #1 informed her that P #1 could not be redirected, had witnessed an assault of a nurse by a patient the prior evening, and ordered that the police be called because the situation was unsafe. The interview with MD #1 on 2/4/21 at 11:11 AM identified that MD #1 spoke with MD #2 at Hospital #1's Main ED to inform him of the situation and P #1's impending transfer. MD #1 indicated that P #1 was transported to the Main Hospital ED on a PEER via ambulance. MD #1 identified that she instructed the transport team to bring P #1 to the Hospital's Main ED instead of Hospital #2's ED as the latter location would constitute an EMTALA (emergency medical treatment and labor act) violation.

MD #1 did not perform a medical screening evaluation prior to P #1's transport to Hospital #1's Main ED.

Interview with SO #1 on 2/4/21 at 1:55 PM identified that although P#1 would not put a mask on, P #1 was very "redirectable" and calm after speaking to P #1 softly. SO #1 indicated that he did not understand why the ED staff wanted P #1 "papered" (PEER) and sent the local police officer inside the ED treatment area to verify that this was their intent for P #1. SO #1 further noted that patients similar to P #1 had been treated at this location in the past.

Interview with MD #3 on 2/4/21 at 2:23 PM identified that the expectation for the physician is to provide care and assess a patient prior to transfer. MD #1 further indicated that he spoke with the Nursing Director of the ED and the Quality Department as this was an EMTALA violation.

The Hospital policy entitled Medical Screening Exam identified that all patients presenting to the Emergency Department must be provided with a Medical Screening Exam (MSE). The MSE must be sufficient to rule out the need for emergency care.

Subsequent to the event, MD #3 spoke with MD #1 and sent an educational email to all ED providers dated 1/26/21 identifying expectations and obligations for medical evaluations and transfers. In addition, ED RNs received EMTALA re-education via huddle or email on 2/1/21, 2/2/21 and 2/5/21.

Based on medical record review, review of hospital policy, review of hospital documentation, review of a security video and interviews for one of twenty-five patients (Patient #1) reviewed who either left the hospital against medical advice (AMA), left the hospital without being seen (LWBS) or transferred to another facility, the hospital failed to ensure that the patient was assessed and appropriate for transfer. The finding includes:

Patient #1 had a history of chronic psychosis, schizoaffective disorder and bipolar disorder. P #1's medical record dated 1/25/21 identified arrived as a walk- in to the satellite ED (emergency department) with a chief complaint of neck and back pain and LWBS forty- one minutes after arrival.

An unauthenticated note in P #1's medical record, undated and untimed, indicated P #1 was not triaged or evaluated by the MD.

The ambulance run sheet dated 1/25/21 noted that P #1 was in the lobby of the satellite ED, was not acting properly, had altered mental status and the local PD (police department) completed a PEER (police emergency evaluation request).

The PEER dated 1/25/21 identified that P #1 took off his/her pants in the lobby and was acting disoriented, suspicious, and agitated, had racing thoughts and was rambling. P #1 was transported to Hospital #1's Main ED in another city from Hospital #1's satellite ED on 1/25/21.

The security video dated 1/25/21 was reviewed on 2/4/21 at 11:40 AM and identified the following, 1. P #1 was disheveled, entered the ED pushing the vestibule W/C (wheelchair) and sat in both the waiting room chair and the W/C. 2. RN #1 entered the waiting area with a medical mask on, extended a medical mask to P #1 and placed the mask on P #1's chest when P #1 did not take the mask. 3. SO (security officer) #1 entered the waiting room through the ED treatment area door and stayed with P #1 as P #1 held his/her own ears, sat in different ED chairs, walked around and removed his/her own pants, boots and socks. 4. A local and state police officer arrived and a team of four emergency responders arrived in the waiting area. 5. P #1 put his/her pants back on, positioned him/herself on the ambulance stretcher without assistance and was wheeled out of the ED. MD #1 did not enter the waiting room to perform an assessment of P #1.

P #1's medical record dated 1/25/21 at Hospital #1's Main ED identified that P #1 was assessed by the Crisis Worker in the ED on 1/26/21, was safe for discharge and was discharged to home on 1/26/21 at 12:02 PM.

An email from MD #1 to MD #3 (ED Chair/Chief) dated 1/25/21 at 11:53 PM identified that MD #1 did not evaluate or see P #1 and asked for police to be called.

Interview with RN #1 on 2/4/21 at 10:11 AM noted that on 1/25/21, P #1 was yelling loudly, not making sense and not following directions. RN #1 further identified that she instructed SO #1 to go to P #1 and police were called per MD #1's direction.

Interview with MD #1 on 2/4/21 at 11:11 AM indicated that RN #1 told her that she didn't feel safe to triage P #1, she watched P #1 on the video screen in the treatment area and ordered that the police be called because the situation was unsafe. The interview with MD #1 on 2/4/21 at 11:11 AM identified that P #1 was transported to the Main Hospital ED on a PEER via ambulance.

Interview with SO #1 on 2/4/21 at 1:55 PM noted that patients similar to P #1 had been treated at this ED location in the past. SO #1 further indicated that he stayed with P #1 and if he had seen a staff member in the waiting room, he would have informed them that P #1's medical needs needed to be addressed.

Interview with MD #3 (ED Chair/Chief) on 2/4/21 at 2:23 PM noted that he spoke with MD #1 on 1/26/21 and informed her that he was concerned that she directed 911 be called without having first assessed the patient.

MD #1 failed to assess P #1 for the need for transfer and P #1 was transferred to Hospital #1's main ED for the same level of care.

The Hospital policy entitled Transfer Criteria identified that patients will be transferred to other institutions when their medical or psychological condition requires procedures and services that can be better met at another facility and such conditions include, in part, patients with severe psychiatric and substance abuse problems who are felt to be in need of, and qualify for state or private psychiatric/detoxification programs.