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Based on interviews and document review, the hospital staff failed to document patient's refusal of diagnostic testing ordered by the Emergency Department physician for 1 (one) of 12 (twelve) patients included in the survey sample. Patient #2.

The findings include:

Patient #2 presented to the hospital emergency department (ED) on 5/10/21 at 11:03 PM, while under an emergency custody order initiated by local police. Police reported Patient #2 parked their car and tried to enter a stranger's home. Documentation by the triage nurse (Staff #9) at 11:04 PM, read in part "alert and oriented to person time incorrect to date and location". A nursing assessment documented at 11:52 PM by Staff #9, found all systems within defined parameters with the noted exception of psychosocial. Under "Behavioral Health Related", presenting signs and symptoms were documented as "confusion". The hospital uses the Broset Violence Checklist (BVC) as a screening for violence/aggression. The BVC screening identified Patient #2 as confused and irritable at 11:53 PM.

A behavioral health consult was requested and Patient #2 was assessed via telehealth at 11:15 PM on 5/10/21 by a representative of the local Community Services Board (CSB). Per Clinician documentation, Patient #2 appeared to have capacity to consent to voluntary psychiatric admission, being able to maintain and communicate choice and understand consequences. The CSB clinician noted that the patient was disoriented to time, place and situation, had impaired thought content, illogical thought process and impaired judgement. The "Mental Status Narrative" read "Ct is A + O x 2. Not alert to situation, time or place. Ct is under the impression (the patient) is in MA or FL. Ct appears to be having mild dementia but no known diagnosis - needs further evaluation. Ct alert to questions per ER Dr. (Staff #6) and (police)." Patient #2 was found by CSB Clinician not to meet criteria for inpatient psychiatric treatment and was released to the ED.

Review of a CSB Clinician narrative note "Supplemental Information" found reports of conversations with the referring police officer and a police Sergeant. Patient #2 stated various beliefs of location i.e., they were in Florida, in New Hampshire at son's home, trying to get to Florida, and trying to get to New Hampshire. Police reported contacting a friend of Patient #2 who reported that patient left two days ago Florida to visit son in New Hampshire. No memory issues were discussed. Police reported also contacting patient's neighbor in Florida who recalled a fall the patient had recently but the neighbor had no other concerns. Multiple attempts were made to contact the patient's son, by the police and by hospital staff with no success.

Per the CSB Clinican written documentation, Patient #2 stated during their conversation not being sure why the officers took them into custody and "they need to be evaluated, not me". Patient #2 reported trying to get back home to Florida. When Patient #2 was confronted with their statement to police officers at the time of incident that they were trying to visit son in New Hampshire, the patient denied stating this. Patient #2 insited during the conversation with the CSB Clinician they were trying to get to Florida and believed they were currently in Florida. The CSB Clinicain further documented Patient #2 was aware of month and date but not year, believing it is 2020. Patient #2 reported no history of dementia, mental illness, violence and no memory issues.

CSB Clinician documented also speaking with ED treating physician (Staff #6), who stated there is no UTI (urinary tract infection) and the patient is fine medically. The CSB Clinician documented Staff #6 stating the patient likely has mild dementia and felt they (the patient) would be more alert after sleep. The CSB Clinician documented Staff #6 reported feeling comfortable with having the patient released to the ED and was planing to allow officers to take Patient #2 to a hotel room for the night.

CSB Clinician was instructed by CSB to contact APS (adult protective services), clinician documentsed this was completed at 00:30 on 5/11/21. The patient did not meet criteria for TDO (temporary detention order).

Staff #6, (ED physician), documented an initial greet date/time as 5/10/21 at 11:08 PM. Staff #6 note documented the patient was "driving from Florida and is trying to go to Maine. The patient thinks that (the patient) is in Massachusetts. The patient is brought to the ED because of confusion. (the patient) is here for medical clearance. The patient has no complaints." Under the "Free Text PE Notes" Staff #6 documented "the patient has no facial asymmetry, is alert and oriented x 3 at this time, affect is normal and the patient is non-anxious".

Review of medical record found no documentation of a nursing re-assessment after completion of the behavioral health evaluation. The medical record contained one set of vital signs, obtained at 11:04 PM. The physician re-evaluation stated status "unchanged". At 11:08 on 5/10/21, the following orders were entered by Staff #6: Blood Alcohol level, Complete Blood Count, COVID-19 screening, EKG- 12 lead, Chest x-ray, BNP, Troponin I, Urinalysis, Urine drug screen and a Comprehensive Metabolic Panel. The chest x-ray was completed; all other orders were canceled at 00:23 AM on 5/11/21. The physician documented the patient was "discharged to home" at 00:50 AM on 5/11/21. Primary impression was documented as "confusion". The discharge instructions were given to the police officer at 00:52 AM. No discharge instructions were documented as being given to the patient. No follow-up care was suggested.

On 12/1/21 at 8:10 AM, the surveyor conducted a telephone interview with Staff #6. Staff #6 discussed the level of confusion Patient #2 was experiencing when examined. Staff #6 stated the patient was confused as to location and why they were being held. Staff #6 stated the patient felt like they were being imprisoned and didn't like that an ECO was placed. Staff #6 stated the patient was able to describe the route to get to New Hampshire in detail including road names and numbers and it was felt the patient had returned to their baseline. The surveyor asked Staff #6 if the patient had been evaluated for a medical reason for their confusion. The lack of lab tests to rule out any medical condition that may be causing or contributing to confusion was discussed in detail. Staff #6 confirmed to the surveyor that checking for a UTI (urinary tract infection) would have been a routine part of the work-up for confusion in a patient intheir nineties. Staff #6 stated the patient refused the ordered tests and wanted to leave. Staff #6 was informed the CSB Clinician documented being told the patient did not have a UTI. Staff #6 denied telling the CSB Clinician this and stated saying they would look for a UTI.

The orders for the various lab tests indicate the physician felt the results were needed to clear the patient medically for a behavioral health admission, so it is reasonable to expect the same tests results would be needed to determine if the patient had a medical reason for the confusion.

Based on Staff #6's statement the patient refused testing, the surveyor asked for documentation of the refusal. Staff #6 stated the refusal was not documented. The surveyor asked if against medical advice forms were filled out before discharge, Staff #6 stated they were not. Staff #6 confirmed that documentation should have been completed to reflect the patient's refusal of testing but stated that documentation sometimes is not as thorough because of what may have been going on with other patient's in the ED and the hospital. Staff #6 stated being the only physician on site during that night shift and may have prioritized patient care delivery to other patiets that limited the completness of documentation for this patient.

The above failure to document was discussed at the time of discovery with Staff #2 and Staff #3, with Staff #6 on 12/1/21 and with the management team prior to exit on 12/2/21. The surveyor reinforced the need for accurate and complete documentation and discussed the added importance the documentation would hold, if an adverse event had occurred after the patient was released.

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Based on interview, document review and during the course of an investigation, the medical record failed to contain documentation of the patient's need for and response to pain medications. For one (1) of twelve (12) patients included in the sample. (Patient #6)

The findings include:

Review of the medical record found Patient #6 arrived to the emergency department (ED) via ambulance on 5/24/21 at 9:50 AM. Patient #6 and their spouse were an out-of -state elderly couple involved in a moter vehicle accident on interstate. Patient #6 was the restrained driver and presented with back pain, sternal pain and abrasion to left arm. Rapid initial assessment at 9:51 AM, documented by Staff #10, documented Patient #6 reported pain as 9 of 10 based on a verbal numeric scale. Pain data read " Numeric pain scale as "Severe pain - 9". Nursing assessment documented by Staff #12 screened the patient for sepsis, falls, and used the Glascow Coma Scale to assess extent of impaired consciousness. Documenting by exception, the Motor vehicle crash trauma assessment documented findings of tenderness/guarding to lower quadrant left and lower quadrant right abdomen. Physical findings were within defined parameters with the exception of musculoskeletal. It was noted that Integumentary was documented as within defined parameters (-skin warm, dry & intact - No complaints of lesions, rash, wounds, bruises, petechiae or abrasions) although the physician documented abrasions to the left forearm and ecchymosis to the chest wall. Vital signs were stable.

Staff #8, (ED physician) documented initial greet date/time of 9:52 AM on 5/24/21. The focused physical exam by Staff #8, documented in part as follows: "Respiratory/Chest....Text/Dict Notes Patient has seatbelt sign extending from the left clavicle across the upper chest to the right breast. She is mildly tender to palpation there is no crepitus." ; "MS Back Text/Dict Notes Patient has tenderness to the lower T-spine and upper lip L-spine. No step-offs no deformity. Mild paraspinal tenderness to the right."; "MS Upper Extrem Text/Dict Notes Ecchymosis to the left forearm with abrasion. (Patient) has an abraded area on the left hand. No obvious deformity of the hand wrist or elbow. Able to move all joints without difficulty." Chest x-ray completed at 11:45 AM reported no acute findings. X-ray of the left hand at 11:39 AM (a limited exam) reported no acute findings. X-ray of lumbar spine at 11:39 AM found osteopenia and scoliosis with mild to moderate multilevel degenerative changes and no acute findings. Staff #8 ordered a Tetanus/Diphtheria Toxoids vaccine which was administered by Staff #12 at 11:13 AM. No other treatments or tests were ordered and patient was discharged to home at 11:55 AM by Staff #8. At 12:17 PM Staff #12 documents "PT D/C. Educated on dxs of back pain, chest bruise, motor vehicle accident (MVA) : contusion from seatbelt, and soft tissue bruise (contusion) is to follow up with PCP in 2-3 days. PT verbalizes understanding and denies questions/concerns. A/O x4. Resp E/U. Skin noted to have several dark purple bruises generalized. Assisted PT to get dressed and ambulate to room 7 to be with husband.". Per the medical record the patient was documented as departed at 12:17 PM on 5/24/21.

Review of the medical record failed to provide evidence of a pain reassessment after the initial assessment at 9:51 AM on 5/24/21 and failed to provide evidence of addressing Patient #6's pain while a patient in the ED. However, at 12:54 PM on 5/24/21, after patient was discharged, Staff #12 documented the following "Pt in room 7 at bedside of husband. 10/10 pain. This RN request provider give medication. Tylenol ordered and given at this time. Pt tolerated well. Still moaning and having difficulty moving." There is no documentation of physician assessment of this discharged patient before or after administration of Tylenol. Review of the medication administration record for Patient #6 found that Tramadol HCL 50mg tablet, additional pain medication, was administered at 4:25 PM by Staff #12. The order was entered by Staff #8 and there was no documentation of physician assessment of this discharged patient before or after the administration of Tramadol. (Tramadol is a pain medicine similar to an opioid and is classified as a synthetic opioid. It acts in the central nervous system (CNS) to relieve pain. Retrieved from https://www.drugs.com/tramadol.html 12/6/21)

Staff #8 was interviewed the afternoon of 12/2/21 in regards to provision of care to Patient #6. Although Staff #8 was informed of the nature of the interview (to provide time to review patient's medical record/refresh memory), Staff #8 stated not remembering a lot about the patient. Staff #8 was asked about the orders for pain medication for a discharged patient and if this was a routine practice. Staff #8 stated it was not a routine but the patient was still in the department and Staff #8 felt it was acceptable to do this. Staff #8 was asked about a hospital policy related to the above mentioned practice. Staff #8 replied they were not sure if there is a policy or not. Staff #3 and Staff #2 were also asked to provide the surveyor with any policy, procedure or protocol available to guide the above practice. Staff #2 and Staff #3 were not able to provide the surveyor with any such documents. Staff #2 stated they had never encountered this practice before.

Surveyor's review of hospital policy titled "Pain Management, NUR615D last revised 05/2020" found the following in part: "1. Adult C. The patient being treated in the Emergency Department, Cancer Center or Ambulatory Care will be assessed for pain upon arrival.", "E. Re-Assessment of Pain: 1. Each patient will be re-assessed for pain throughout the hospital stay. 2. Each patient will be reassessed within 1 hour of administration for all pain medications" and "I. Documentation: Document the patient assessment, re-assessment, treatment, medication administration and education and comments in the Computerized patient care system."

The above failure of Staff #8 to document an assessment of Patient #6 prior to ordering a medication for Patient #6 after the patient was discharged from the ED was discussed with Staff #2 and Staff #3 at the time of discovery and with the management team prior to exit on 12/2/21, as well as lack of reassessment of patient 1 hour after pain medication was administered.