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Based on facility policy review, document review, credentialing files, medical record review and interview, it was determined the Governing Body (GB) failed to assume responsibility for the oversight for care and services provided in the Dedicated Emergency Department (DED) for psychiatric patients seeking emergency care.

The findings included:

1. The GB failed to assume responsibility for the care provided to the patients by the Medical Staff who failed to ensure an appropriate examination was performed for patients who presented to the DED with suicidal ideations, suicided attempts and/or drug overdoses seeking emergency care. Refer to A 049

2. The GB failed to assume responsibility and ensure that contracted services in the DED were staffed with qualified practitioners and provided appropriate medical screenings when presented to the DED with suicide attempts, suicidal threats and drug overdose. Refer to A 083

3. The GB failed to ensure psychiatric services were provided to emergency department patients. Refer to A 091 and A 1104.

Based on facility policy review, document review, medical record review, credentialing files, and interview, it was determined the Governing Body (GB) failed to assume responsibility for the care provided to the patients by the Medical Staff who failed to ensure an appropriate examination was performed for 3 of 9 (Patient #5, 7 and 24) sampled patients who presented to the Dedicated Emergency Department (DED) with suicidal ideations, suicide attempts and/or drug overdoses seeking emergency care.

The findings included:

1. Review of the "Rules and Regulations of the Medical Staff of [name of hospital] documented, "3.6-2 GUIDELINES FOR CALL CONSULTATIONS Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) An patient know or suspected to be suicidal..."


2. Review of the facility policy, "Suicide Assessment/Precautions Policy" documented, "12. Collaborate with physician to determine level of observation and obtain order as soon as possible: a. Possible Suicide Risk 1) Indications: expressing vague suicidal ideation without a plan; no demonstrated self-destructive behavior; chronic suicidal thoughts.
2) Observe every 30 minutes for patient safety.
3) Initiate frequent verbal contact.
b. Serious Suicide Risk 1) Indications: patient admitted following suicide attempt, verbalizes intent to harm self; has concrete/specific plan; exhibits disorganized and/or psychotic behavior; also indicated for medically stabilized patient following recent suicide attempt. 2) Continuous observation (hospital or contracted personnel). 13. Discuss psychiatric services and appropriate setting for treatment with physician/health team members."

3. Medical record review for Patient #5 documented on 1/15/10 at 2:51 PM the patient arrived via Emergency Medical Services (EMS) with chief complaint of an attempted suicide by hanging himself with a sheet. There was no documentation the patient was referred by the DED Physician #1 for a psychiatric evaluation to determine psychiatric stability for discharge back to prison.

During an interview in the administrative conference room on 7/11/12 at 9:10 AM, the Director of Clinical Risk Management verified there was an absence of an appropriate assessment prior to being discharged back to prison.

4. Medical record review for Patient #7 documented the patient was arrested after a Motor Vehicle Incident (MVI) and sent via ambulance to the DED on 1/22/10. While in the ambulance, the patient told the Emergency Medical Technician-Intravenous (EMT-IV) that he wanted to die. The EMT-IV reported this to the nurse. The nurse documented the patient had stated if he goes to jail he would beat himself to death. The patient was discharged by Physician #2 back to the jail without a psychiatric evaluation being performed to determine the patient's psychiatric stability. While in the DED there was no documentation of continuous observation per policy.

On 1/23/12 at 5:31 PM, Patient #7 returned to the ED after a documented suicide attempt in jail by hanging. Upon arrival the patient's pupils were fixed and dilated. He was transferred via helicopter to another hospital for a higher level of care and expired on 1/24/10.

Review of the Chief Medical Examiners report dated 1/24/10 documented the cause of death was suicide.

During an interview in the administrative conference room on 7/9/12 at 3:00 PM, the Risk Manager was asked about Patient #7's treatment in the DED, and why a psychiatric evaluation was not completed. She stated, "...may have asked for a psych eval [evaluation] to be done at the jail...sometimes that happens if [patient] in police custody...once he got to jail...have a psych eval..." When asked if the facility would have normally done the evaluation at the ED, she stated, "Yes, and I think that is our protocol now..."

During a telephone interview in the Administrative conference room on 7/11/12 at 2:20 PM, the Nurse Practitioner (NP) who treated Patient #7 was asked how a suicidal patient was treated in the DED. She stated, "...usually have somebody suicidal have psych [psychiatric] department from the hospital come down and talk with that person ..." The NP further stated, "...in my opinion..say suicidal, I think they should be evaluated before leaving ..."

5. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 at 5:00 AM for possible drug ingestion. Review of the Emergency Department Record documented the Medical Screening Exam (MSE) was started at 5:40 AM. The suicide risk assessment was deemed low risk. The chief complaint was substance abuse agent unknown and anxiety. The clinical impression was, "Substance abuse." Urine drug screen was positive for amphetamines, opiates and tetrahydrocannabinol. Physician #2 discharged the patient at 6:09 AM with condition unchanged and in the custody of the sheriff. There was no documentation a psychiatric evaluation was performed to determine psychiatric stability prior to being discharged from the DED.

6. Review of the "EMERGENCY ROOM MEDICAL REVIEW COMMITTEE MINUTES" dated 2/9/10 documented a review of Patient #7's chart for the DED admission on 1/22/10. The Practitioner review findings documented, "...Unfortunate outcome but hospital ER [Emergency Room] acted appropriately..."

7. Review of the DED scheduling for January 2010 through March 2011 documented Physician #2 worked an average of 19-twelve hour shifts a month.

8. Review of Physician #2's Delineation of Privileges form documented no qualifications or approval to perform psychiatric evaluations for determining patient mental stability. Physician #2 had documented speciality as Ophthalmology.


Review of Physician #2 credentialing file documented he was placed on probation from the State board of licensure for 3 years and assessed a civil monetary penalty for gross malpractice, ignorance, negligence or incompetence in the course of medical practice.

Review of the Credentialing Committee Minutes beginning 11/15/10 documented the committee was informed that Physician #2's medical license was on probationary status effective 9/14/10. The committee made a decision to place Physician #2 on focus review for 6 months.

On 1/10/11 the Credentials Committee made a decision to place Physician #2's reappointment on hold to gather additional data.

On 2/14/11 the Credentialing Committee was informed that Physician #2 had one chart of unanticipated death in February 2011 sent out for peer review and one additional record pending review of a pediatric case seen in the DED in October 2010. Concerns were identified with both cases reviewed.

On 3/14/12 the Credentialing Committee approved Physician #2 for reappointment to practice in the DED for one year with the following requirements: 1) Physician has attended the [named physician re-education program] regarding patient assessment and will submit findings to the Credentials Committee. 2) Shifts worked will be reduced by 50%, not to exceed 8-10 per month. 3) Physician will be placed on focused professional practice review for one year.

9. During an interview in the Administrative conference room on 7/11/12 at 9:00 AM, the Risk Manager and Director of Clinical Risk Management were asked how physician #2 had been deemed competent to work the DED. The Director of Clinical Risk Management stated, "MD with surgical experience, he went to medical school, 3 references from ER [emergency room] doctors when he came here...emergency care modules...had been doing other ED [DED] facilities..." When asked how he was competent from a psychiatry aspect, the Director of Clinical Risk Management stated, "I'm not sure..." At 9:15 AM, the Risk Manager was asked if there was documented education for the DED physicians regarding the changes to the Emergency Department Order Sheet. She stated, "[ED Director] discussed it with all her doctors in the ED... not documented in their minutes..." The Risk Manager again verified the discussion with the contracted ED company physicians was not documented.

10. During an interview in the conference room on 7/11/12 at 12:45 PM, the Director of Clinical Risk Management verified that the contracted DED physicians were categorized as active staff and they follow the by-laws of the hospital. She further verified that the credentialing process was the same for the contracted DED physicians.

11. During an interview in the Administrative conference room on 7/11/12 at 1:00 PM the Medical Staff Coordinator stated she was not aware of any changes to the credentialing process as a result of the suicide of Patient #7.

12. During an interview in the Administrative conference room on 7/11/12 At 1:05 PM, the Director of Clinical Risk Management was asked if she expected to see psychiatric evaluation approval on the Delineation of Privileges form. She stated, "If they [ED Doctors] are going to be doing a psychiatric evaluation, I would expect it to be on there [Delineation of Privileges form]."

Refer to A 0347 and A 1104

Based on document review, medical record review and interview, it was determined the Governing Body failed to assume responsibility and ensure the DED contracted physicians' services were qualified to perform an appropriate medical screening examination for 3 of 9 (Patients #5, 7, and 9) patients who presented to the DED with suicide attempts, suicidal threats and drug overdose.

The findings included:

1. Review of the "Rules and Regulations of the Medical Staff of [name of hospital] documented, "3.6-2 GUIDELINES FOR CALL CONSULTATIONS Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) An patient know or suspected to be suicidal ..."

2. Review of the 2010 Bylaws of the Medical Staff documented, "...ARTICLE FIVE DELINEATION OF PRACTICE PRIVILEGES 5.1 EXERCISE OF PRIVILEGES 5.1-1 IN GENERAL A practitioner providing clinical services at this hospital...exercise only those clinical privileges specifically granted to him by the Board...Regardless of the level of privileges specifically granted, each practitioner must pledge to provide or arrange for appropriate and timely medical care for his patients in the hospital and to obtain consultation when necessary for the safety of his patient or when required by the rules or other policies of the staff, any of its clinical units, or the hospital..."


3. Review of the facility contract with the [DED physicians' services] dated 12/1/00 and most recently signed on 3/23/12, documented, "...RECITALS...B. Hospital operates an emergency department on its premises...which requires coverage by physicians, physician assistants, and nurse practitioners who have the training, experience, and qualifications necessary to practice emergency medicine as emergency physicians, physician assistants and nurse practitioners...I OBLIGATIONS OF CONTRACTOR. Contractor agrees to the following: 1. Medical Services. Contractor shall supply qualified Physicians to staff the Emergency Department...(a)...Contractor shall require the Physicians and Physician Extenders to administer care to patients as required by applicable federal, state and local laws, rules and regulations, including but not limited to The Emergency Medical Treatment and Active Labor Act (EMTALA)..."

4. Medical record review for Patient #5 documented on 1/15/10 at 2:51 PM the patient arrived via Emergency Medical Services (EMS) with chief complaint of attempted suicide by hanging himself with a sheet. There was no documentation the patient was referred by DED Physician #1 for psychiatric evaluation to determine psychiatric stability for discharge back to prison.

During an interview in the administrative conference room on 7/11/12 at 9:10 AM the Director of Clinical Risk Management verified there was an absence of an appropriate assessment prior to being discharged back to prison.

5. Medical record review for Patient #7 documented the patient was arrested after a Motor Vehicle Incident and sent via ambulance to the DED on 1/22/10. While in the ambulance, the patient told the Emergency Medical Technician Intravenous (EMT-IV) that he wanted to die. The EMT-IV reported this to the nurse and it was documented by the nurse the patient had stated if he goes to jail he would beat himself to death. DED Physician #2 discharged the patient back to jail without a psychiatric evaluation to determine the patient's psychiatric stability. While in the DED there was no documentation of continuous observation per policy.

On 1/23/12 at 5:31 PM, Patient #7 returned to the DED after a documented suicide attempt in jail by hanging. Upon arrival the patient's pupils were fixed and dilated. He was transferred via helicopter to another hospital for a higher level of care and expired on 1/24/10.

Review of the Chief Medical Examiners report dated 1/24/10 documented the cause of death as suicide.

During an interview in the administrative conference room on 7/9/12 at 3:00 PM, the Risk Manager was asked about Patient #7's treatment in the DED and why a psych evaluation was not completed in the DED. She stated, "...may have asked for a psych eval [evaluation] to be done at the jail...sometimes that happens if [patient] in police custody...once he got to jail...have a psych eval..." When asked if the facility would have normally done the evaluation at the DED, she stated, "Yes, and I think that is our protocol now..."

During a telephone interview in the administrative conference room on 7/11/12 at 2:20 PM, the Nurse Practitioner (NP) who treated Patient #7 was asked how a suicidal patient was treated in the ED. She stated, "...usually have somebody suicidal have psych [psychiatric] department from the hospital come down and talk with that person ..." The NP further stated, "...in my opinion..say suicidal, I think they should be evaluated before leaving ..."

6. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 at 5:00 AM for possible drug ingestion. Review of the Emergency Department Record documented the Medical Screening Exam (MSE) was started at 5:40 AM. The suicide risk assessment was deemed low risk. The chief complaint was substance abuse agent unknown and anxiety. The clinical impression was, "Substance abuse." Urine drug screen was positive for amphetamines, opiates and tetrahydrocannabinol. DED Physician #2 discharged the patient at 6:09 AM with condition unchanged and in the custody of the sheriff. There was no documentation a psychiatric evaluation was performed in the DED to determine the patient's psychiatric stability.

7. During an interview in the Administrative conference room on 7/11/12 at 9:00 AM, the Risk Manager and Director of Clinical Risk Management were asked how DED Physician #2 had been deemed competent to work the DED. The Director of Clinical Risk Management stated, "MD with surgical experience, he went to medical school, 3 references from ER doctors when he came here...emergency care modules...had been doing other ED facilities..." When asked how he was competent from psychiatry aspect, the Director of Clinical Risk Management stated, "I'm not sure..." At 9:15 AM, the Risk Manager was asked if there was documented education for the DED physicians regarding the changes to the Emergency Department Order Sheet. She stated, "[ED Director] discussed it with all her doctors in the ED [DED]... not documented in their minutes..." The Risk Manager again verified the discussion with the contracted DED company physicians was not documented.

During an interview in the conference room on 7/11/12 at 12:45 PM, the Director of Clinical Risk Management verified that the contracted DED physicians were categorized as active staff and they should follow the by-laws of the hospital. She further verified that the credentialing process was the same for the contracted DED physicians.

During an interview in the Administrative conference room on 7/11/12 at 1:00 PM, the Medical Staff Coordinator was asked about the scope of practice for contracted DED physicians and the Medical Staff Coordinator referred to the delineation of privileges form. Review of the form revealed no documentation of psychiatric privileges or qualifications for Physician #2. The Director of Clinical Risk Management verified there were no psychiatric privileges addressed on the form. At 1:05 PM, the Director of Clinical Risk Management was asked if she expected to see psychiatric evaluation approval on the form. She stated, "If they [ED Doctors] are going to be doing a psychiatric evaluation, I would expect it to be on there."

During a telephone interview in the Administrative conference room on 7/11/12 at 1:20 PM, the Regional Medical Director for the contracted DED services was asked how the company ensured qualified physicians staffed the DED. He stated, "Based on their record, experience, medical school, experience in the emergency department...we have a risk management committee...checks past history...[online training modules]..." He stated that he was unable to give specifics about the 2009 modules Physician #2 had completed because they change each year. When asked about the scope of practice for an DED physician, he stated, "Stabilization and management of any patient...jack of all trades...should be able to stabilize any patient who presents to the ED..."

Refer to A 0347

Based on policy review, medical record review, credentialing files, and interview, it was determined the governing body failed to ensure the contracted Dedicated Emergency Department (DED) physicians were qualified to provide an appropriate medical screening examinations for patients who presented to the DED seeking emergency psychiatric care for 2 of 2 (Physician's #1 and 2) contracted DED physicians.

The findings included:

1. Review of the credentialing files for Physician #1 and Physician #2 revealed no documentation the physicians were qualified to perform psychiatric evaluations to determine mental stability on patients admitted to the facility emergency department.

2. Review of the "Rules and Regulations for the Medical Staff" documented, 12.
"3.6-2 GUIDELINES FOR CALL CONSULTATIONS, Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) A patient known or suspected to be suicidal ... " Physician #1's specialty was Family Practice and Physician #2's specialty was Ophthalmology.

Review of the facility policy, "Suicide Assessment/Precautions Policy" documented,"
12. Collaborate with physician to determine level of observation and obtain order as soon as possible: a. Possible Suicide Risk
1) Indications: expressing vague suicidal ideation without a plan; no demonstrated self-destructive behavior; chronic suicidal thoughts.
2) Observe every 30 minutes for patient safety.
3) Initiate frequent verbal contact.
b. Serious Suicide Risk
1) Indications: patient admitted following suicide attempt, verbalizes intent to harm self; has concrete/specific plan; exhibits disorganized and/or psychotic behavior; also indicated for medically stabilized patient following recent suicide attempt.
2) Continuous observation (hospital or contracted personnel). 13. Discuss psychiatric services and appropriate setting for treatment with physician/health team members."

3. Medical record review for Patient #5 documented on 1/15/10 at 2:51 PM the patient arrived via EMS (emergency medical services) with chief complaint of attempted suicide by hanging himself with a sheet. There was no documentation the patient was referred by DED Physician #1 for a psychiatric evaluation to determine psychiatric stability for discharge back to prison.

During an interview in the administrative conference room on 7/11/12 at 9:10 AM the Director of Clinical Risk Management verified there was an absence of an appropriate assessment prior to being discharged back to prison.

4. Medical record review for Patient #7 documented the patient was arrested after a motor vehicle collision (MVC) and sent via ambulance to the DED on 1/22/10. While in the ambulance, the patient told the Emergency Medical Technician-Intravenous (EMT-IV) that he wanted to die. The EMT-IV reported this to the nurse, and it was documented by the nurse that the patient had stated if he goes to jail he would beat himself to death. DED Physician #2 discharged the patient to jail without a psychiatric evaluation to determine the patient's psychiatric stability. While in the DED, there was no documentation of continuous observation per policy.

On 1/23/12 at 5:31 PM, Patient #7 returned to the DED after a documented suicide attempt in jail by hanging. Upon arrival the patient's pupils were fixed and dilated. He was transferred via helicopter to another hospital for a higher level of care and expired on 1/24/10.

Review of the Chief Medical Examiners report dated 1/24/10 documented the cause of death was suicide.

5. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 for possible drug ingestion. The chief complaint was substance abuse agent unknown and anxiety. There was no documentation of a primary care physician. Physician #2 discharged the patient in the custody of the sheriff. There was no documentation a psychiatric evaluation was performed to determine the patient's psychiatric stability. While in the DED there was no documentation of continuous suicide observation.

6. During a telephone interview in the Administrative conference room on 7/11/12 at 2:20 PM, the Nurse Practitioner (NP) who treated Patient #7 was asked how a suicidal patient was treated in the ED. She stated, "...usually have somebody suicidal have psych [psychiatric] department from the hospital come down and talk with that person ..." The NP further stated, "...in my opinion..say suicidal, I think they should be evaluated before leaving ..."

Refer to A-1104

Based on credential file review, medical record review and interview, it was determined the facility failed to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program with the care and services of the patients' best health interest in mind.

This resulted in failure of the hospital to recognize and act on issues surrounding the inadequate examinations/assessments of patients who presented in custody of law enforcement to the hospital's Dedicated Emergency Department (DED) with psychiatric instability.

The findings included:

1. The hospital failed to monitor suicidal patients, safety of services, and quality of care delivered to patients with psychiatric instability.
Refer to A 275 and A 1104.

Based on medical record review, credentialing file review and interview, it was determined the facility failed maintain an active and ongoing Quality Assessment and Performance Improvement (QAPI) program to monitor suicidal patients, safety of services, and quality of care for patients with psychiatric instability who presented to the Dedicated Emergency Department (DED) seeking emergency care.

The findings included:

1. Review of the Delineation of Privileges Emergency Room form in the credentialing file for Physician #1 dated 2/4/2009 revealed no documentation Physician #1 was qualified to perform psychiatric evaluations to determine mental stability in the DED. Review of Physician #1's State medical license documented training and specialty was in Family Practice.

2. Review of the Delineation of Privileges Emergency Room form in the credentialing file for Physician #2 dated 3/10/07, and reappointment on 4/14/09, revealed no documentation Physician #2 was qualified to perform psychiatric evaluations to determine mental stability in the DED. Review of Physician #2's State medical license documented training and specialty in Ophthalmology.

3. Review of the "EMERGENCY ROOM MEDICAL REVIEW COMMITTEE MINUTES" dated 2/9/10 documented a review of Patient #7's chart for admission date of 1/22/10. The minutes documented, "...Review Type: Unanticipated death...Practitioner Reviewer findings: Unfortunate outcome but hospital ER [Emergency Room] acted appropriately. No documentation issues; appropriate management...Follow-up continue to monitor ..."

3. Review of the medical record for Patient #7 revealed the patient presented to the DED on 1/22/10 following a motor vehicle accident and had made statements that he "wants to die", and "if I go to jail I'll beat myself to death." Patient #7 did not receive a psychiatric evaluation while in the DED and was transported to jail. On 1/23/10 the patient was transported back to the DED for attempted suicide by hanging. Upon arrival to the DED, the patient's pupils were fixed and dilated. The patient was transferred to higher level of care and expired on 1/24/12. The cause of death was suicide.

4. Review of the Emergency Room Committee minutes dated 5/11/2010 documented no sentinel events and to continue to monitor for sentinel events.

Review of the Dashboard Report revealed there was no documentation the number of re-admission's within 72 hours was addressed. In October, 2009 monitoring for suicide prevention constant observation documentation was 50%, and Psych Screening documentation for January, 2010 was 80%. There was no documentation in the minutes to address these issues.

5. Review of the Joint Conference/Board of Directors Meeting dated 2/17/11 documented a Sentinel Event Activity report was present. Review of the Sentinel Event Activity report documented, "one unanticipated death within 48 hours of ED visit [referring to the death of Patient #7]." There was no action taken as a result of the sentinel event.

During an interview in the administrative conference room on 7/10/12 at 3:00 PM the hospital Risk Manager stated, " Credentialing and By-Laws were not changed after this event [the unanticipated death of Patient #7]. "

Refer to A083

Based on facility policy review, document review, medical record review and interview, it was determined the hospital's Medical Staff failed to provide quality care and services. The Medical Staff failed to ensure patients who presented to the Dedicated Emergency Department (DED) with suicidal attempts, suicidal ideation or drug overdose received appropriate and adequate medical screening exam (MSE), treatment and care within the hospital's capabilities.

The findings included:

1. The Medical Staff failed to ensure patients who presented to the DED with suicidal attempts or ideations received an adequate and appropriate MSE prior to discharge.

2. The Medical Staff failed to ensure qualified physicians staffed the DED.

Refer to A 0347

Based on document review, facility policy review, medical record review, and interview, it was determined the medical staff failed to assume responsibility for the oversight of physicians practicing in the Dedicated Emergency Department (DED) and failed to ensure an appropriate examination and evaluation was performed for 3 of 9 (Patients #5, 7 and 24) sampled patients that presented to the DED seeking treatment for suicidal attempt, suicidal threats or drug overdose.

The findings included:

1. Review of the "Rules and Regulations of the Medical Staff of [name of hospital] documented, " 3.6-2 GUIDELINES FOR CALL CONSULTATIONS Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) An patient know or suspected to be suicidal ..."


2. Review of the facility policy, "Suicide Assessment/Precautions Policy" documented, "...12. Collaborate with physician to determine level of observation and obtain order as soon as possible: a. Possible Suicide Risk 1) Indications: expressing vague suicidal ideation without a a plan; no demonstrated self-destructive behavior; chronic suicidal thoughts. 2) Observe every 30 minutes for patient safety. 3) Initiate frequent verbal contact. b. Serious Suicide Risk 1. Indications: patient admitted following suicide attempt verbalizes intent to harm self; has concrete/specific plan; exhibits disorganized and/or psychotic behavior; also indicated for medically stabilized patient following recent suicide attempt. 2. Continuous observation (hospital or contracted personnel). 13. Discuss psychiatric services and appropriate setting for treatment with physician/health team members"

3. Medical record review for Patient #5 documented on 1/15/2010 at 2:51 PM the patient arrived at the DED via Emergency Medical Services (EMS) with a chief complaint of attempted suicide by hanging with a sheet himself.

DED Physician #1 imitated an examination of the patient on arrival documenting the patient had a suicide attempt, "...hung self (tried) but sprinkler he tied sheet to broke ...psych problems ...situation problems 'in prison' ... " Physician #1 further documented on the "T-System Documentation Guidelines" form the patient had past history of psychiatric problems and bipolar disorder. Under the physical exam section of the form Physician #1 documented, "Psych depressed, suicidal." Physician #1's clinical impression was "suicide attempt." The section on the T-System form for Medical Clearance for Psychiatric Referral was left blank. There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed. The patient did not receive every 30 minute suicide checks while in the DED. The patient was discharged back to prison at 5:56.

4. Medical record review for Patient #7 documented on 1/22/10 at 3:40 PM the patient arrived via ambulance following a motor vehicle accident. Review of the Ambulance Patient Care Report documented, "...Pt stated he wanted to die ..."

Review of the T-system Emergency Nursing Record for Motor Vehicle Collision documented the patient was triaged at 3:40 PM with a chief complaint of head and neck pain, left hip pain. The nurse also documented, "Pt states if he goes to jail he will beat himself to death. Pt extremely belligerent, in cuffs. "

Review of the T-system Emergency Department Record noted the patient was seen on arrival by DED Physician #1. Review of the Psych section of the form documented mood and affect was circled, indicating an affirmative. Progress notes written by Physician #1 documented, "pt intoxicated - unable to clear c-spine clinically. CT head, c-spine neg ...Pt made suicidal statement to nurse (though not to me). Transferred care to Dr. [physician #2] ... If d.c ' [discharged] to jail, place on suicide precautions with psych eval [evaluation] stat per protocol." Physician #1 documented the clinical impression was suicidal ideation, MVC and polysubstance abuse.

Review of the T-system Emergency Department Record signed by the Family Nurse Practitioner (FNP) documented the patient was seen at 1800 (6 PM) for an examination. Under the psychiatric physical exam section of the form, the FNP documented the patient was "sleepy." At 7:15 PM, the FNP documented, "Will awake to verbal stimulation very combative during catheterization." The lab results revealed the patient was positive for cocaine, opiates and benzodiazepine and negative for alcohol. A CT of the head documented sinus disease and the CT of the neck was normal.
The FNP documented the clinical impression was, "...polysubstance abuse."

A disposition order time was 7:15 PM to "sent to [named county jail] with sheriff's deputy." There was no documentation of the patient's condition at discharge by the FNP. A progress note by the FNP dated 1/22/10, with no time, documented, "Given transfer sheets to [names deputy sheriff]. He is to be on suicide precaution with q [every] 15 " [minute] [abbreviation for checks]. He is also to be closely observed due to polysubstance abuse. He did not verbalize suicidal ideations or depression. He states, 'I'm pissed because I have to go to jail.' Able to awaken with stimulus. "

A "Prisoner Medical Clearance Report" dated 1/22/10 and signed by Physician #2 documented, "I have examined the prisoner [patient] and find him acceptable for admission to the jail providing the following conditions are met. Suicidal precautions q 15 minute checks." There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed. The patient did not receive every 30 minute suicide checks while in the DED. The patient was discharged back to prison.

On 1/23/10 at 5:31 PM, Patient #7 was transported back to the DED following an attempted suicide by hanging himself. Upon arrival to the DED, the patient was intubated, pupils fixed and dilated, with ligature marks around his neck. The patient had urinated and defecated in his pants. A MSE was performed at 5:45 PM and the patient was transferred via helicopter to another hospital for a higher level of care where he expired on 1/24/10.

Review of the Chief Medical Examiners report dated 1/24/10 documented the cause of death was suicide.

5. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 at 5:00 AM for possible drug ingestion. Review of the Emergency Department Record documented the MSE was initiated at 5:40 AM. The suicide risk assessment was deemed low risk. The chief complaint was substance abuse agent unknown and anxiety. The clinical impression was, "Substance abuse." Urine drug screen was positive for amphetamines, opiates and tetrahydrocannabinol. The discharge instructions/patient information documented Physician #2 was the attending in the ED and the patient had no regular primary care physician. The patient was discharged at 6:09 AM with condition unchanged and in the custody of the sheriff. There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed.

6. Review of the "EMERGENCY ROOM MEDICAL REVIEW COMMITTEE MINUTES" dated 2/9/10 documented a review of Patient #7's chart for the admission date 1/22/10. The minutes documented, "...Review Type: Unanticipated death ... Practitioner Reviewer Findings: Unfortunate outcome but hospital ER [Emergency Room] acted appropriately. No documentation issues; appropriate management ...Follow-up continue to monitor ..."

7. Review of the DED contracted physicians' schedules for January 2010 through March 2011 documented Physician # 2 worked the DED the following 12 hour shifts:

a. January 2010 - 15 of 31 days
b. February 2010 - 18 of 28 days
c. March 2010 - 20 of 31 days
d. April 2010 - 20 of 30 days
e. May 2010 - 20 of 31 days
f. June 2010 - 20 of 30 days
g. July 2010 - 24 of 31 days
h. August 2010 - 24 of 31 days
i. September 2010 - 20 of 30 days
j. October 2010 - 23 of 31 days
k. November 2010 - 19 of 30 days
l. December 2010 - 19 of 31 days
m. January 2011- 17 of 31 days
n. February 2011 - 16 of 28 days
o. March 2011 - 15 of 31 days

8. Review of the State medical license for Physician # 2 documented his training and specialty was in Ophthalmology.

Review of Physician #2's credentialing file documented the following from the [state] Department of Health Board of Licensure, regarding Physician # 2 medical license, "...ACTION License placed on probation for 3 years, must meet certain terms and conditions: assessed $1,000 civil penalty REASON: Gross malpractice, or a pattern of continued or repeated malpractice, ignorance, negligence or incompetence in the course of medical practice EFFECTIVE DATE 9/14/10..."

Review of the Delineation of Privileges Emergency Room form in the credentialing file for Physician #2 dated 3/10/07, revealed no documented of qualifications or an approval to perform psychiatric evaluations to determine patients' mental stability.

Review of the "Ongoing Professional Practice Review- Hospital Based Staff July- October 2010" documented, "...[Physician #2] ...Adverse Licensure Action Disciplinary Action Report On 9/14/10 his license was placed on probation for 3 years and he must meet certain terms and conditions ...The associated Board Order describes an event in April 2009, where [Physician #2] examined a patient in the emergency room at [named another hospital] who was complaining of chest pain. [Physician #2] diagnosed the patient with pleurisy and discharged him with pain pills and instructions to follow up with his physician. The patient was brought back into the emergency room one hour later by the EMS and was pronounced dead on arrival. In May 2009 [Physician #2] emergency department privileges were suspended upon request of the Patient Care Committee at [named hospital above] ..."

Review of the "CREDENTIALS COMMITTEE MINUTES" dated 11/15/10 documented, "...One emergency room physician had disciplinary action report on Tennessee licensure dated September 14, 2010. Motion made by [named physician committee member] and seconded by [named physician committee member] that physician [Physician #2] be placed on focus review for the next 6 months..."

Review of the "CREDENTIALS COMMITTEE MINUTES" dated 12/13/10, documented, "...[Physician #2] Emergency Medicine - On focus review for 6 months. November- 308 contacts, 1 death, 0 referrals to committee ..."

Review of the "CREDENTIALS COMMITTEE MINUTES " dated 1/10/11 documented, "...The Credentials Committee recommended placing the reappointment on hold to gather additional data ...The Credentials Committee placed him on focus review in November 2010 for 6 months ...Physician also requested write in privilege for abdominal thoracentesis for removal of ascetic fluid ...December 357 contacts- 0 referrals to committee ..."

Review of the "CREDENTIALS COMMITTEE MINUTES" dated 2/14/11 documented, "Reappointment ...[Physician #2] ...No action taken on reappointment at this time. Focus review still in progress. One chart of unanticipated death in February sent for outside peer review. One additional record pending review: Patient seen in ER, less than 24 hours seen by PCP [primary care physician] & [and] transferred to [named pediatric hospital] for ruptured appendix. Referred to Surgery Service for review ..."

Review of the outside peer review form for the pediatric case treated in the DED on 10/13/10 documented, "Findings/History: Patient seen in ED on 10/10/10 for abdominal pain. Less than 24 hours later seen by PCP and shipped to [named pediatric hospital ...Practitioner Reviewer Findings: Further laboratory evaluation would have been appropriate. History of fever, anorexia, abdominal pain in an ill-appearing child- appendicitis has to be high on differential ..." The peer review was dated 3/14/2011.

Review of the outside peer review form for the unanticipated death treated in the DED on 2/5/11, documented, "...several indicators for concern and need for more aggressive initial evaluation appears natural course of illness but could have been interpreted c [with] earlier diagnosis of DKA [Diabetic ketoacidosis] & ? [question] sepsis." The Peer review scoring on the form documented the outcome as Permanent (major) adverse outcome with a concern with the diagnosis and judgment. The peer review form was not dated by the reviewing physician. The committee received the documents on 9/12/11.

Review of the "CREDENTIALS COMMITTEE MINUTES" dated 3/14/11 documented, "...The Credentials Committee approved Reappointment to the Hospital Based Staff in Emergency Medicine for one year with the following action plan: 1) Physician has attended the [named physician re-education program] regarding patient assessment and will submit findings to the Credentials Committee. 2) Shifts worked will be reduced by 50%, not to exceed 8-10 per month. 3) Physician will be placed on focused professional practice review for one year. Physician also requested privileges for abdominal centesis for removal of ascetic fluid. The Credentials Committee noted procedure is not performed in the ER and write in privileges are not allowed. Privilege not approved..."

Review of a facsimile dated 2/11/11 in Physician #2's credentialing file documented the physician was given 24 emergency room charts by the [above named physician re-education program]. Physician #2 was instructed to review and submit the charts to the [physician re-education program] by 2/28/11. There was no documentation in the file that the charts were submitted as required to complete the requirement set forth by the Credentialing Committee on 3/14/11.

9. During an interview in the Administrative conference room on 7/9/12 at 3:00 PM, the Risk Manager was asked about Patient #7's treatment in the DED and why a psychiatric evaluation was not performed in the DED. The Risk manager stated, "...may have asked for a psych eval [evaluation] to be done at the jail...sometimes that happens if [patient] in police custody...once he got to jail...have a psych eval..." When asked if the facility would have normally done the psychiatric evaluation in the DED, she stated, "Yes, and I think that is our protocol now...[physician] order sheet now I believe has basic psych eval listed on it..."

10. During an interview in the Administrative conference room on 7/11/12 at 9:10 AM, the Director of Clinical Risk Management verified Patient #5 did not have an appropriate assessment before being discharged back to the prison.

11. During an interview in the Administrative conference room on 7/10/12 at 1:50 PM, the Medical Staff Coordinator was asked what prompted the action of the credentialing committee for Physician #2. The Medical Staff Coordinator stated, "...September 14, 2010 that...I was made aware of it...I was notified from our corporate office that his [Physician #2] license...on probation...he was put on focused review...he submitted his re-appointment application on 11/5/10..." When asked to explain a focused review, she stated, "...when someone is approved, new physician, focused for 6 months..." When asked about requirements for reappointment, she stated, "We require one peer reference." When asked how the information was validated she stated, "...send affiliation letters to hospitals to find out if [physician] in good standing..." She further verified that the credentialing committee makes the decision regarding physician competency.

12. During an interview in the Administrative conference room on 7/11/12 at 9:00 AM, the Risk Manager and Director of Clinical Risk Management were asked how physician #2 had been deemed competent to work the DED. The Director of Clinical Risk Management stated, "MD with surgical experience, he went to medical school, 3 references from ER [emergency room]doctors when he came here...emergency care modules...had been doing other ED facilities..." When asked how he was competent from a psychiatry aspect, the Director of Clinical Risk Management stated, "I'm not sure..." At 9:15 AM, the Risk Manager was asked if there was documented education for the DED physicians regarding the changes to the Emergency Department Order Sheet. She stated, "[ED Director] discussed it with all her doctors in the ED... not documented in their minutes..." The Risk Manager again verified the discussion with the contracted ED company physicians was not documented.

13. During an interview in the Administrative conference room on 7/11/12 at 9:40 AM, the Quality Manager stated that on 10/18/10 the Medical staff Coordinator was informed that Physician #2 was on a report from the State board. She stated in November 2010 the information was presented to the credentialing committee and Physician #2 was placed on focused review for six months.


14. During an interview in the conference room on 7/11/12 at 12:45 PM, the Director of Clinical Risk Management verified that the contracted DED physicians were categorized as active staff and they should follow the by-laws of the hospital. She further verified that the credentialing process was the same for the contracted DED physicians.

15. During an interview in the Administrative conference room on 7/11/12 at 1:00 PM the Medical Staff Coordinator stated she was not aware of any changes to the credentialing process as a result of the suicide of Patient #7. When asked about the scope of practice for contracted DED physicians, the Medical Staff Coordinator referred to the Delineation of Privileges form. Review of the form revealed no documentation of psychiatric privileges or qualifications for Physician #2. The Director of Clinical Risk Management verified there were no psychiatric privileges addressed on the form. At 1:05 PM, the Director of Clinical Risk Management was asked if she expected to see psychiatric evaluation approval on the form. She stated, "If they [ED Doctors] are going to be doing a psychiatric evaluation, I would expect it to be on there [Delineation of Privileges form]."


16. During a telephone interview in the Administrative conference room on 7/11/12 at 1:20 PM, the Regional Medical Director for the contracted DED company was asked how the company ensured qualified physicians staffed the ED. He stated, "Based on their record, experience, medical school, experience in the emergency department...we have a risk management committee...checks past history...[online training modules]..." He stated that he was unable to give specifics about the 2009 modules Physician #2 had completed because they changed each year. The Regional Medical Director was unable to provide proof of the training. When asked about the scope of practice for an DED physicians, he stated, "Stabilization and management of any patient...jack of all trades...should be able to stabilize any patient who presents to the ED..."

Based on medical record review, credentialing files, medical staff rules and regulations, and interview, it was determined the facility failed to ensure medical staff providing care in the Dedicated Emergency Department (DED) followed policies for psychiatric consultations for suicidal patients, and failed to ensure qualified staff provided medical screening treatment and stabilization.

The findings included:

1. The facility failed to ensure the contracted DED physicians followed DED polices for providing quality care and services, and were competent and privileges were granted to perform appropriate evaluations for all patients presenting to the DED.

Refer to A 1104

Based on medical record review, credentialing files, medical staff rules and regulations, and interview, it was determined the contracted Dedicated Emergency department (DED) physicians failed to follow policies for performing an appropriate medical screening examination for all patients presenting to the DED seeking emergency care for 2 of 2 (Physician #1 and 2) contracted DED physicians. The contracted DED physicians failed to ensure 3 of 9 (Patients #5, 7, and 24) patients with psychiatric instability received the necessary care and services offered by the hospital for stabilization of their psychiatric conditions.

The findings included:

1. Review of the Delineation of Privileges Emergency Room form in the credentialing file for Physician #1 dated 2/4/2009 documented the following: "All applications for privileges will be reviewed and further documentation or clarifications may be requested. Check only those privileges that are within your scope of practice for which you are qualified by training and/or experience..." The form documented, "Differential Diagnosis, Clinical history, Physical examination..." were checked and approved on 3/9/2009 by the Department Chairman, Credentials Committee Chairman and Chief of Staff. The applicant was appointed to the Hospital Based category in the Department of Medicine with clinical privileges requested approved. The Governing Board approved appointment with staff category and clinical privileges as recommended by the Medical Executive Committee on 3/10/2009. There was no documentation in the credentialing file Physician #1 was qualified to perform psychiatric evaluations to determine mental stability in the Emergency Department. Review of Physician #1's State medical license documented training and specialty was in Family Practice.

2. Review of the Delineation of Privileges Emergency Room form in the credentialing file for Physician #2 dated 3/10/2007 documented the following: "All applications for privileges will be reviewed and further documentation or clarifications may be requested. Check only those privileges that are within your scope of practice for which you are qualified by training and/or experience ..." The form documented, "Differential Diagnosis Clinical history, Physical examination..." were checked and approved on 5/14/2007 by the Department Chairman, Credentials Committee Chairman and Chief of Staff. The applicant was appointed to the Hospital Based category in the department of ER [Emergency Room] with clinical privileges requested approved. The Governing Board approved appointment with staff category and clinical privileges as recommended by the Medical Executive Committee on 5/24/2007. Reappointment to the medical staff was completed on 4/14/2009 with no recommendations. There was no documentation in the credentialing files that Physician #2 was qualified to perform psychiatric evaluations to determine mental stability in the Emergency Department. Review Physician #2's State medical license documented training and specialty in Ophthalmology.

3. Review of the "Rules and Regulations of the Medical Staff of [name of hospital] documented, "3.6-2 GUIDELINES FOR CALL CONSULTATIONS Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) An patient know or suspected to be suicidal..."

4. Medical record review for Patient #5 revealed on 1/15/2010 at 2:51 PM the patient arrived at the DED via Emergency Medical Services (EMS) with a chief complaint of attempted suicide by hanging himself with a sheet. DED Physician #1 imitated examination of the patient on arrival to the DED documenting the patient, "...hung self (tried) but sprinkler he tied sheet to broke ...psych problems ...situation problems 'in prison'..." The physician further documented on the hospital's T-System Documentation Guidelines form the patient had past history of psychiatric problems and bipolar disorder. Under the physical exam section of the form, the physician documented, "Psych depressed, suicidal." The documented clinical impression was "suicide attempt." Under the section on the T-System form for Medical Clearance for Psychiatric Referral the area was left blank. There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed. The patient was discharged back to prison at 5:56.

Review of the Tennessee Department of Correction Referral for Emergency Care form sent back to prison with the patient documented, "Current Complaint/Patient History: I/M [inmate] found hanging in cell-unknown amount of time-upon arrival of nurse I/M on floor c [with] blood coming from mouth-difficulty breathing ... REPORT FROM OUTSIDE FAC [Hospital DED] ...Treatment given: none. CT [computed tomography] - no bony or obvious soft tissue injury...Pt needs to be on suicide watch, See PCP [primary care physician] if any throat or neck symptoms and have psych eval [evaluation]." This form was signed by DED Physician #1.

During an interview in the administrative conference room on 7/11/12 at 9:10 AM, the Director of Clinical Risk Management verified there was an absence of an appropriate assessment prior to being discharged back to prison and that police prisoners and jail persons did get different treatment during the time period (referring to 1/2010).

5. Medical record review for Patient #7 documented he was arrested after a motor vehicle accident and sent via ambulance to the DED. While in the ambulance, the patient made a statement to the Emergency Medical Technician-Intravenous (EMT-IV) that he wanted to die. He also made a statement to the DED nurse that "if he goes to jail he will beat himself to death."

Review of the T-system Emergency Nursing Record for Motor Vehicle Collison (MVC) documented the patient was triaged at 3:40 PM with a chief complaint of head and neck pain, left hip pain. The nurse also documented, "Pt states if he goes to jail he will beat himself to death. Pt extremely belligerent, in cuffs."

Review of the T-system Emergency Department Record revealed the patient was examined on arrival to the DED by Physician #1. Review of the Psychiatric section of the form documented mood and affect was circled, indicating an affirmative. Progress notes written by Physician #1 documented, "pt intoxicated...Pt made suicidal statement to nurse (though not to me). Transferred care to Dr. [physician #2] ... If d.c'd [discharged] to jail, place on suicide precautions with psych eval stat per protocol." Physician #1 documented the clinical impression was suicidal ideation, MVC and polysubstance abuse.

A Prisoner Medical Clearance Report dated 1/22/10 and signed by Physician #2 documented, "I have examined the prisoner and find him/her acceptable for admission to the jail providing the following conditions are met. Suicidal precautions q 15 minute checks." There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed.

On 1/23/10 at 5:31 PM Patient #7 was transported back to the DED following an attempted suicide by hanging himself in jail. Upon arrival to the DED the patient was intubated, pupils fixed and dilated and had visible ligature marks around neck. The patient had urinated and defecated in his pants. A examination was performed at 5:45 PM and the patient was transferred via helicopter to another hospital for a higher level of care where he expired on 1/24/10.

Review of the Chief Medical Examiners report dated 1/24/10 documented the cause of death was suicide.

6. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 at 5:00 AM for possible drug ingestion. Review of the Emergency Department Record documented the MSE was initiated at 5:40 AM. The suicide risk assessment was deemed low risk. The chief complaint was substance abuse agent unknown and anxiety. The clinical impression was, "Substance abuse." Urine drug screen was positive for amphetamines, opiates and tetrahydrocannabinol. The ExitCare Patient Information (pre-printed discharge information) documented Physician #2 was the attending in the DED, and the patient had no regular primary care physician. The patient was discharge at 6:09 AM with condition unchanged and in the custody of the sheriff. There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed.


7. During a telephone interview in the Administrative conference room on 7/11/12 at 1:20 PM, the Regional Medical Director for the contracted ED company was asked how the company ensured qualified physicians staffed the ED. He stated, "Based on their record, experience, medical school, experience in the emergency department...we have a risk management committee...checks past history...mine field navigator [on-line computer training] modules..." He stated that he was unable to give specifics about the 2009 modules Physician #2 completed because they change each year. When asked about the scope of practice for an ED physician, he stated, "Stabilization and management of any patient...jack of all trades...should be able to stabilize any patient who presents to the ED..."

8. During a telephone interview in the Administrative conference room on 7/11/12 at 2:10 PM, Physician #1 was asked if there was a different procedure for patients that are in custody of law enforcement? Physician #1 stated, "Yes, prison/jail system, procedures in place for prisoners. Med clears them in the ER or could get crisis consult then send to jail for suicide precautions and they consult psych."