HospitalInspections.org

Based on record review and interview, the hospital failed to ensure compliance with

42 CFR 489.24 (a) and (c) Appropriate Medical Screening Examination to determine if there was an emergency psychiatric condition, in that, 1 of 20 patients (Patient #1) did not have a complete medical screening examination, and


42 CFR 489.24 (e)(1) and (2) Appropriate Transfer in that, 1 of 20 patients (Patient #1) was transported to a county hospital by police from this hospital without appropriate transfer including no MOTs (Memorandum of Transfer), no hospital/Physician acceptance of the patient transfer, no physician signature/Patient acknowledgement, and/or Medical Records sent with the patient to the subsequent acute hospital.


It was determined that the hospital failed to provide

42 CFR 489.24 (a) and (c) Appropriate Medical Screening Examination to determine if there was an emergency psychiatric condition,
(Cross Reference to Tag 2406)

42 CFR 489.24 (e) (1) and (2) Appropriate Transfer/Discharge
(Cross reference to Tag 2409)

Based on record review and interview, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exist, in that,

1 of 20 patients (Patient #1) did not have a complete and timely medical screening examination to determine if there was an emergency psychiatric condition.

Findings:

Patient #1's Nursing documentation stated, "6/15/2019 at 23:33 PM Triage: agitated, distressed, obeys commands...23:51 PM agitated...refusing all care...6/16/2019 00:23 AM Ic (sp/IV) d/c by patient provider aware. Pt states that a**hole pissed me off when he told me that I could not leave. I am about to loose (sp) it. pt given urinal, but proceeds to urinate all over the floor...GVPD (Grapevine Police) at bedside for assistance with being aggressive. Pt states I just hurt all over and want the pain to end. GVPD called supervisor, will transport to subsequent hospital after d/c. Personnel #5 at bedside to assist with d/c...1:40 PM Pt released to police custody. Pt allowed to call father to inform that he is being discharged from ED (Emergency department) Pt in NAD (no acute distress)...Pt states I don't want to go with the police. Pt ambulatory with steady gait..."

Patient #1's physician documentation stated, "Examination 23:59 PM...complaints of suicidal ideation...symptoms were moderate...Pt (patient) request pain medications. He threatens to leave, Get Dangerous and go home if he does not get pain meds...positive suicidal gestures...positive for anxiety, depression, drug dependence, alcohol dependence...All other systems are negative...hemodynamically stable...uncooperative, Affect is irritable...1:00 PM very clear suicidal ideations prior to arrival...arrival at emergency department patient has had an inconsistent story...patient has been uncooperative and at times aggressive with staff as well as towards providers...police here and seen and discussed this case with me as well as the patient. He has stated that he is not willing to go to treatment and wanted to go home. He is unreliable at this time and is being manipulative in regards to his desire for additional pain medicine stating that he is in alcohol withdrawal but has normal vitals and ETOH (alcohol) level of 180. Uncomfortable with this patient being discharged home but discussing with Grapevine Police and they are going to take him into custody. They are planning on transporting him to subsequent hospital for further psychiatric evaluation versus taking him to jail for intoxication...I will discharge the patient..."

Patient #1's record did not evidence a complete medical screening examination to determine if there was psychiatric emergency medical condition.


The 6/15/2019 Grapevine Police Department's report included the Detention Warrant and reflected, "22:41 hours...Grapevine medics were evaluating...Officers were requested by FD (Fire Department) personnel to accompany to Baylor ER. After being medically assessed by Baylor ER staff, Patient #1 was medically cleared. It was apparent that Patient #1 was still in imminent danger of harming himself. Patient #1 demonstrated and expressed desire to harm himself by forcefully removing the IV in his arm twice and stating he was in pain and desired to end his life due to pain of withdrawals from narcotics. Patient #1 was detained and transported to (subsequent hospital name) for a mental evaluation. An Emergency Detention Application was filled out..." The "Notification of Emergency Detention" reflected, "6/15/19 time: 0120..." (assuming this was completed 6/16/19 at 0120, during the time he was at the ER, not 22 hours prior to the ER).


During an interview on 1/13/2020 at 11:55 AM, Personnel #5 reviewed the record and confirmed, "Patient #1 had a moderate risk of suicide and was aggressive toward staff. We don't restrain. We could not continue with care. He was refusing care. The police were present. He was released to Police custody."

During an interview on 1/13/2020 at 2:12 PM, Personnel #8 was asked about discharging an aggressive patient versus an appropriate transfer for psych admission. Personnel #8 discussed an EMTALA expert advice they received to not cross big men with guns (referring to the police). They take the patient into custody and remove them from the ER.

During an interview on 1/13/2020 ending at 2:45 PM, Personnel #7 was asked to discuss the lack of transfer to the subsequent hospital on 6/16/2019 for Patient #1. Personnel #7 stated, "This happens more frequently. When we involve the police with agitated or aggressive patients. Police ask if a patient is medically cleared. If we say yes, they decide to take the patient into custody and take them out. They don't even tell us if they are going to jail or another hospital. We try to get them to stay so we can follow our process of Psychiatric assessment, recommendation, and then transfer, but they know that can take 6 to 8 hours sometimes. The police do not want to stay/wait that long with the patient. They know that the county hospital is funded to provide the psychiatric care for Tarrant County and they can take them there, drop them off, and avoid sitting all day/night with them. I tell them the process we have to follow, but they are big guys with guns. All I can do is document that they are taking him away."

Personnel #7 was asked if they called in the police. Personnel #7 stated, "No. They showed up with the ambulance. He was aggressive. He had spray painted a suicide note." Personnel #7 was asked if the police prevented his process. Personnel #7 stated, "Yes. He (the Patient) needed observation/Admit. He was intoxicated. Decision making ability was questionable. After a few hours, then we could assess it. They decided to take him into custody. He would be supervised by the police. They didn't say they were taking him to jail or subsequent hospital. That is why I put it in the note as versus."

During a telephone interview on 1/15/2020 at 1:01 AM, Personnel #6 was asked about Patient #1. Personnel #6 stated, "Police and Fire stayed the whole time. We were all female staff that night. He kept being disrespectful. I think he was under arrest for vandalism. It was a lot of work to get him Medically cleared. He was release to their (police) care. They took him away, maybe to jail." Personnel #6 was told her documentation stated - will transport to subsequent hospital after discharge. Personnel #6 stated, "If that is what I documented, that is what I heard. I would not have documented that out of nowhere."

During a telephone interview 1/15/2020 ending at 7:27 PM, Officer #1, Grapevine Police Department was asked about the Emergency Detention Warrant dated 6/15/2019 at 120 or 130 AM (hard to decide, given the emergency room visit was 6/15/19 at night) when was it done. Officer #1 stated, "Yes, I completed it (6/16/19) around the time I took him from (one hospital to the other). I found out the hard way that I wasn't supposed to transport him there. The nurse there told me that patients have to go by ambulance. It wasn't my understanding or the other officer's that night."

Officer #1 was asked if he knew that the first hospital could do the Psych eval, why was it not completed there. Officer #1 stated, "I was told the patient was medically cleared, but did not feel comfortable with letting him go home or to my jail in his state. I felt he needed further psych evaluation. It was hectic. He was hectic. They said they couldn't restrain him and he was refusing treatment. I don't recall if they told me to take him or not. I don't want to say something, when I don't remember. We have to stay with them through the whole thing."



Patient #1's emergency room record at the recipient hospital reflected, "BHE Triage 9:48 PM Arrived...Legal Status: DW - Detention Warrant...Per DW, pt (patient) went over to neighbor's house and held knife to his throat saying he would kill himself if he did not get drugs...11:24 PM Physician Exam...discharged from (subsequent hospital) this AM...guarded, evasive, and refuses interview...dysphoric...preparing. Expressed suicide risk...2nd visit in 24 hours...Placed in Observation...Order: 6/18/2019 8:07 AM...Admit to Behavioral Health - Bipolar Disorder..."

Based on record review and interview, the hospital failed to provide an Appropriate Transfer, in that,

1 of 20 patients (Patient #1) was transported to a county hospital by police from this hospital without appropriate transfer including no hospital/Physician acceptance of the patient transfer, no MOTs (Memorandum of Transfer), no Patient acknowledgement, and/or Medical Records sent with the patient to the subsequent acute hospital.

Findings


Patient #1 was brought to the emergency room by an ambulance accompanied by the police on 6/15/19 at 23:33 PM with alcohol use, suicidal ideation, and possible overdose. The patient pulled out (d/c) his IV (intravenous line) in the ambulance prior to transfer to the ER.

Patient #1's Nursing documentation stated, "6/15/2019 at 23:33 PM Triage: agitated, distressed, obeys commands...23:51 PM agitated...refusing all care...6/16/2019 00:23 AM Ic (sp/IV) d/c by patient provider aware. Pt states that a**hole pissed me off when he told me that I could not leave. I am about to loose (sp) it. pt given urinal, but proceeds to urinate all over the floor...GVPD (Grapevine Police) at bedside for assistance with being aggressive. Pt states I just hurt all over and want the pain to end. GVPD called supervisor, will transport to subsequent hospital after d/c. Personnel #5 at bedside to assist with d/c...1:40 PM Pt released to police custody. Pt allowed to call father to inform that he is being discharged from ED (Emergency department) Pt in NAD (no acute distress)...Pt states I don't want to go with the police. Pt ambulatory with steady gait..."

Patient #1's physician documentation stated, "Examination 23:59 PM...complaints of suicidal ideation...symptoms were moderate...Pt (patient) request pain medications. He threatens to leave, Get Dangerous and go home if he does not get pain meds...positive suicidal gestures...positive for anxiety, depression, drug dependence, alcohol dependence...All other systems are negative...hemodynamically stable...uncooperative, Affect is irritable...1:00 PM very clear suicidal ideations prior to arrival...arrival at emergency department patient has had an inconsistent story...patient has been uncooperative and at times aggressive with staff as well as towards providers...police here and seen and discussed this case with me as well as the patient. He has stated that he is not willing to go to treatment and wanted to go home. He is unreliable at this time and is being manipulative in regards to his desire for additional pain medicine stating that he is in alcohol withdrawal but has normal vitals and ETOH (alcohol) level of 180. Uncomfortable with this patient being discharged home but discussing with Grapevine Police and they are going to take him into custody. They are planning on transporting him to subsequent hospital for further psychiatric evaluation versus taking him to jail for intoxication...I will discharge the patient..."

Patient #1's record did not evidence a subsequent hospital/Physician acceptance for the patient transfer, MOTs (Memorandum of Transfer), no Patient acknowledgement, and/or Medical Records sent with the patient other than his discharge paperwork.

The 6/15/2019 Grapevine Police Department's report included the Detention Warrant and reflected, "22:41 hours...Grapevine medics were evaluating...Officers were requested by FD (Fire Department) personnel to accompany to Baylor ER. After being medically assessed by Baylor ER staff, Patient #1 was medically cleared. It was apparent that Patient #1 was still in imminent danger of harming himself. Patient #1 demonstrated and expressed desire to harm himself by forcefully removing the IV in his arm twice and stating he was in pain and desired to end his life due to pain of withdrawals from narcotics. Patient #1 was detained and transported to (subsequent hospital name) for a mental evaluation. An Emergency Detention Application was filled out..." The "Notification of Emergency Detention" reflected, "6/15/19 time: 0120..." (assuming this was completed 6/16/19 at 0120, during the time he was at the ER, not 22 hours prior to the ER).

Patient #1's subsequent acute facility emergency record (patient was taken by police from the first hospital) reflected, "6/16/2019...BHE (Behavioral Health Emergency) Triage 2:40 AM Legal status: DW - Detention Warrant. Denies SI, HI, AV/H. (Suicidal, Homicidal, Auditory/Visual Hallucinations) He is oriented to person, place, time/date, situation...Cooperative...Ativan 2 mg (milligrams) 3:05 AM...Librium 25 mg...Nicoderm 21 mg/24 hour patch...Vitamin B1 300 mg...Multivitamin 1 tablet...Folic Acid 1 mg...(all given at) 8:05 AM...10:35 AM (Physician Exam approximately 8 hours after arrival) suicidal threats last night after argument with brother...In AM after sleeping for several hours and sobering up. Cooperative with eval. Reports feeling better...denies intentions of harming himself now...no distress...depressed...no expressed Suicide Risk. Not ideating...12:25 PM Discharge Home; Follow up/Referrals: Subsequent hospital Behavioral Clinic, Substance Abuse Treatment, Counseling..."


During an interview on 1/13/2020 at 11:55 AM, Personnel #5 reviewed the record and confirmed, "Patient #1 had a moderate risk of suicide and was aggressive toward staff. We don't restrain. We could not continue with care. He was refusing care. The police were present. He was released to Police custody."

During an interview on 1/13/2020 at 2:12 PM, Personnel #8 was asked about discharging an aggressive patient versus an appropriate transfer for psych admission. Personnel #8 discussed an EMTALA expert advice they received to not cross big men with guns (referring to the police). They take the patient into custody and remove them from the ER.

During an interview on 1/13/2020 ending at 2:45 PM, Personnel #7 was asked to discuss the lack of transfer to the subsequent hospital on 6/16/2019 for Patient #1. Personnel #7 stated, "This happens more frequently. When we involve the police with agitated or aggressive patients. Police ask if a patient is medically cleared. If we say yes, they decide to take the patient into custody and take them out. They don't even tell us if they are going to jail or another hospital. We try to get them to stay so we can follow our process of Psychiatric assessment, recommendation, and then transfer, but they know that can take 6 to 8 hours sometimes. The police do not want to stay/wait that long with the patient. They know that the county hospital is funded to provide the psychiatric care for Tarrant County and they can take them there, drop them off, and avoid sitting all day/night with them. I tell them the process we have to follow, but they are big guys with guns. All I can do is document that they are taking him away."

Personnel #7 was asked if they called in the police. Personnel #7 stated, "No. They showed up with the ambulance. He was aggressive. He had spray painted a suicide note." Personnel #7 was asked if the police prevented his process. Personnel #7 stated, "Yes. He (the Patient) needed observation/Admit. He was intoxicated. Decision making ability was questionable. After a few hours, then we could assess it. They decided to take him into custody. He would be supervised by the police. They didn't say they were taking him to jail or subsequent hospital. That is why I put it in the note as versus."

During a telephone interview on 1/15/2020 at 1:01 AM, Personnel #6 was asked about Patient #1. Personnel #6 stated, "Police and Fire stayed the whole time. We were all female staff that night. He kept being disrespectful. I think he was under arrest for vandalism. It was a lot of work to get him Medically cleared. He was release to their (police) care. They took him away, maybe to jail." Personnel #6 was told her documentation stated - will transport to subsequent hospital after discharge. Personnel #6 stated, "If that is what I documented, that is what I heard. I would not have documented that out of nowhere."

During a telephone interview 1/15/2020 ending at 7:27 PM, Officer #1, Grapevine Police Department was asked about the Emergency Detention Warrant dated 6/15/2019 at 120 or 130 AM (hard to decide, given the emergency room visit was 6/15/19 at night) when was it done. Officer #1 stated, "Yes, I completed it (6/16/19) around the time I took him from (one hospital to the other). I found out the hard way that I wasn't supposed to transport him there. The nurse there told me that patients have to go by ambulance. It wasn't my understanding or the other officer's that night."

Officer #1 was asked if he knew that the first hospital could do the Psych eval; Why was it not completed there. Officer #1 stated, "I was told the patient was medically cleared, but did not feel comfortable with letting him go home or to my jail in his state. I felt he needed further psych evaluation. It was hectic. He was hectic. They said they couldn't restrain him and he was refusing treatment. I don't recall if they told me to take him or not. I don't want to say something, when I don't remember. We have to stay with them through the whole thing."

The facility's policy, 1/06/2020 effective date, showed, "Care of Patients with Behavioral Health Emergencies - ED" required, "Involuntary detention order - the practice of using legal means as part of the Texas law to commit a person to psychiatric facility or the like against their will or over their protests for observed behavior constituting a clear and present danger to the individual and or others. This may include actual or attempted substantial self-injury, attempted or inflicted serious bodily harm to another, acting in a manner that indicates a person may not be able to care for him herself without assistance, attempting suicide or showing high risk of suicide...Apprehension by Peace Officer without Warrant (APOWW) - enacted by and on active duty a licensed peace officer...Medical clearance - the process required to reach the point, with reasonable clinical confidence, at which remaining medical problems are treatable on an outpatient, non-emergent basis. This is the point at which it is medically appropriate to discharge the patient from either the ED or transfer to a psychiatric facility."