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Based on interview and record review the facility failed to follow their internal policies regarding provision of an appropriate medical screening examination (MSE), and documentation of a thorough, overall re-assessment of patients' risk of suicide/homicide ideations or assaultive behaviors, or the patients' abilities to meet their essential needs prior to discharge, for two (Patients #28 and #43) of seven psychiatric patients with suicidal ideations (SI) reviewed that presented for treatment in the main campus Emergency Department (ED). The main ED's average daily census is 175, with a monthly census of approximately 5,250. The main campus census was 212 and the Behavioral Health campus census was 36.

This failure had the potential to affect all psychiatric patients presenting to the main campus ED that required an MSE and could delay further treatment/examination or result in patient deterioration/injury.

Findings included:

1. Review of the facility's policy titled, "Emergency Department Call Coverage," reviewed 11/28/13, showed the following:
- All persons who come to the ED of the Hospital shall receive an appropriate MSE, by a qualified medical health person (QMP/QMHP) within the hospital's capability to determine whether or not an emergency medical condition (EMC) exists.
- If an EMC exists, the patient will be stabilized or transferred in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) if the hospital has capacity (the ability to accommodate the patient requesting examination or treatment, such as qualified staff, beds, etc.).
- If a psychiatric patient has a substantial risk of harming him/herself, or others, or is unable to provide for his/her own food, clothing, shelter, or other essential human needs or that substantial impairment or obvious deterioration of the patient's judgment may result in the patient's inability to function independently, means the patient has an EMC.

2. Review of the facility's Medical Staff Bylaws, revised 12/13/13, showed all Medical Staff Members of the ED and other health care providers with appropriate education, training and experience, or clinical privileges may perform the MSE.

3. During an interview on 04/14/14 at 3:10 PM, Registered Nurse (RN) ED Manager, Staff E, stated that the main campus ED had access to the behavioral health (BH) ED and/or QMHPs from the BH campus across the street, at all times.

4. Review of Patient #28's main campus ED triage record showed that the patient presented, via ambulance, on 03/01/14 at 4:05 AM. The patient was in police custody after having been involved in a fight and stated that, "I'm going to kill myself [SI] and take down a lot of people [HI]." The patient verbally confirmed he was both suicidal (SI) and homicidal (HI). The patient had a history of substance and alcohol abuse.

Review of Patient #28's laboratory values, dated 03/01/14, showed the patient was currently positive for cocaine and marijuana use, and had an alcohol level of 93 mg/dL (anything above 80 mg/dL is considered high and over 300 is toxic). The patient also had a high level of Creatinine Kinase (CK) of 1,738 IU/L(normal=38-234 IU/L, an elevated level can be indicative of a cardiac problem or many other central nervous system injuries).

Review of physician's orders showed an order for a mental health follow-up related to SI risk dated 03/01/14 at 1:25 PM.

Review of ED physician notes, timed 4:47 AM, 7:30 AM, 8:44 AM, and 1:10 PM, showed the patient would need observation until sober. The patient was violent and a danger to himself and others, requiring chemical and mechanical restraint. The patient had a history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day activities). If the patient's CK level improved, the patient may be discharged home. The patient's CK level did not improve so the ED physician wanted to admit the patient. The patient's admission diagnoses included an altered mental state, drug abuse and an elevated CK.

Review of ongoing Nurses' Notes showed at 4:42 PM, the patient wanted to go home, but was still belligerent with staff saying,"I will tear this out of my arm, I'm ready." At 5:05 PM, the patient wanted to leave against medical advice (AMA). The patient was discharged, AMA, at 5:10 PM.

Review of the entire ED record showed no documented thorough, overall re-assessment to determine Patient #28's SI risk prior to discharge. The record showed no documented evidence of an alcohol level re-draw prior to discharge. (The facility failed to document if the patient had a home, shelter, or police station to go to, if he was accompanied by anyone such as family, police, etc., or if he could meet his essential needs per their EMC definition and policy).

5. During an interview on 04/16/14 at 2:23 PM, ED Physician, Staff H, stated that when a psychiatric patient with alcohol intoxication presented, they typically got a drug screen and waited until the patient sobered up as the patient usually felt differently about SI/HI. If the ED Physician determined the patient was not at harm toward self or others, and if the patient had a place to go, the patient was discharged. If still SI/HI, a BH evaluation was conducted (the facility failed to follow their policy).

6. During an interview on 04/17/14 at 9:32 AM, ED RN Staff J (triaged Patient #28) stated that Patient #28 stated that the ED physician decided if the patient had a BH evaluation, and when the patient was discharged.

7. During an interview on 04/17/14 at 9:18 AM, ED RN, Staff K (discharged Patient #28), stated that no alcohol level labs were re-drawn on patients to determine sobriety prior to discharge. The ED physician examined the patients for appropriate discharge if SI.

8. During an interview on 04/16/14 at 12:40 PM, Accreditation Officer, Staff A, stated that the facility had the capacity and capability to provide a BH evaluation to Patient #28 on 03/01/14.

9. Review of Patient #43's main campus ED triage record showed the patient presented, via ambulance, on 01/01/14 at 3:27 PM with complaints of a, "Plan to shoot myself [SI], if I had a gun." The patient had a history of depression and had not been taking his anti-depressant medication. The patient's mood was sad and he was intoxicated.

Review of the ambulance record, dated 01/01/14, showed a concerned citizen called the ambulance because the patient was suicidal. The patient had six large beers and had felt suicidal for the past week. The patient told ambulance crew, "If I could get your gun I'd shoot myself," and that he had no reason to live.

Review of Patient #43's history showed diagnoses of bipolar disorder, alcohol-induced mood disorder with daily alcohol intake, and routine use of anti-depressant medications.

Review of Patient #43's laboratory values showed the patient had a critical alcohol level of 379 mg/dL (anything over 300 is considered toxic) at 4:38 PM.

Review of physician's orders dated 01/01/14 showed an order for a mental health follow up related to suicide risk. There was no order for fluids or medications.

Review of the ED Physician's note dated 01/01/14 at 3:50 PM, showed the patient had, "No specific plan for suicide so can be d/c'd (discharged) if he recants." Later, at 9:00 PM, the patient denied SI, said he would be safe and wanted to go home. The patient was discharged at 9:14 PM (only five hours later).

Review of the entire ED record showed no documented thorough, overall re-assessment to determine SI risk prior to discharge. There was no alcohol level re-draw prior to discharge. (The facility failed to document if the patient had a home, shelter, or police station to go to, if he was accompanied by anyone such as family, police, etc., or if he could meet his essential needs per their EMC definition and policy).

10. During an interview on 04/16/14 at 12:40 PM, Accreditation Officer, Staff A, stated that the facility had the capacity and capability to provide a BH evaluation to Patient #43 on 01/01/14.

11. During an interview on 4/17/14 at 10:05 AM, ED RN, Staff L stated that, originally, the discharge plan for Patient #43 included sending him across the street for a BH evaluation related to his SI. When the patient recanted his SI, the Physician was notified and the ED Physician decided to discharge the patient.

Staff L stated that a BH evaluation and discharge was at the ED Physician's discretion. It was also up to the ED Physician if there was a re-draw of alcohol level labs prior to discharge to verify sobriety.

Staff L had no idea of where Patient #43 was discharged to, if anyone accompanied him, or if he drove away, even though the discharge documentation showed he was discharged "home" by "private vehicle. (Contrary to hospital policy, the patient was discharged with no known place to go.)

12. During an interview on 04/16/14 at 2:03 PM, ED Physician, Staff I, stated that BH crisis QMHPs were available for patient evaluation at all times. Staff I stated that if a patient was actively suicidal, a BH evaluation was at the discretion of the ED Physician. Staff I stated that she discharged Patient #43 because he was not SI after sobering up and he wanted to go home-she could not keep the patient against his will. Staff I confirmed she had the capability to do a 96-hour hold for a patient's safety.

Based on observation and interview the facility failed to post signs specifying the rights of individuals in the Emergency Department (ED), and information indicating whether or not the hospital participates in the Medicaid program, in seven of seven specialty ED rooms (Pod S-utilized for psychiatric and/or incarcerated patients). The main campus census was 212 and the Behavioral Health (BH) campus census was 36.

Findings included:

1. Even though requested, the facility provided no policy regarding the required ED signage.

2. Observation on 04/14/14 at 3:29 PM, showed seven isolated, locked, ED rooms, referred to as Pod S. There were no Medicaid signs, or signs showing the rights of individuals coming to the ED in the entry of Pod S, at the Nurses' Station, in the corridors, or in any of the seven examination rooms.

During a concurrent interview, ED Manager, Staff E, confirmed there were no signs on this unit as the patients had a tendency to remove them. "Patients pull things off the walls."

3. An observation of Pod S on 04/16/14 at 2:35 PM, showed staff failed to display the required signage, even though given the opportunity for two days.

Based on record review and interviews, the facility failed to ensure:
-Staff made consistent and accurate entries into the Obstetrical (OB) Triage Log Book for each individual who presented to the OB Unit seeking care for an emergency medical condition.
-Staff kept a central log of patients coming to the main campus Emergency Department (ED) that was complete, including disposition for 196 patients reviewed over a six-month period.
The disposition was inaccurate for five (#29, #33, #34, #38 and #50) out of seven patients reviewed.
This had the potential to affect every individual seeking emergency care from either the OB Triage or the ED.
The facility's typical number of visits was 2,700 every six months.
The census at the facility's main campus was 212.

Findings included:

1. Even though requested, the facility failed to provide a policy regarding ED Log completion.

2. Review on 04/14/14 at approximately 4:30 PM, showed staff were not consistent in completing entries in the OB Triage Log. The OB Triage Log for the past six months had the following missing entries:
-Date and time admitted;
-Room at time;
-Triage;
-Discharge time.

3. During an interview on 04/15/14 at 10:55 AM, Staff V, Registered Nurse (RN), OB Director, stated that the OB Triage Log did not always have the patient's disposition filled out.

4. Review of ED Logs from 10/01/13 through 04/15/14, showed 196 patients' entries had no disposition listed and seven patients were listed as "expired."

5. During interviews on 04/15/14 at 11:13 AM, and 2:20 PM, Staff E, ED Manager, confirmed the ED Logs should include the disposition. Staff E stated that RNs complete the log. Staff E stated that the disposition was built-in to the computer to be a "mandatory" field and she could not explain why/how the logs had missing disposition entries.

6. Review of the "expired" patients' records showed five (#29, #33, #34, #38, and #50) of the seven had not actually expired, but were discharged from the ED.

7. During an interview on 04/16/14 at 10:46 AM, Staff E, confirmed the five patients were indeed alive at the time of discharge, and the entries of "expired" were in error. Staff E demonstrated how staff marked a circle in the computer system to indicate the disposition of the patient. Options included, discharged, admitted, expired, and transferred.



12450

Based on observation, interview and record review the facility failed to conduct an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed, on two (Patients #28 and #43) of seven psychiatric patients with suicidal ideations (SI) reviewed that presented for treatment in the main campus Emergency Department (ED). The main ED's average daily census is 175, with a monthly census of 5,250. The main campus census was 212 and the Behavioral Health (BH) campus census was 36.
This failure had the potential to affect all psychiatric patients presenting to the main campus ED, as the patient's condition could deteriorate, without proper treatment.

Findings included:

1. Review of the facility's policy titled, "Emergency Department Call Coverage," reviewed 11/28/13, showed the following: - All persons who come to the ED of the Hospital shall receive an appropriate MSE, by a qualified medical health person (QMP/QMHP) within the hospital's capability to determine whether or not an emergency medical condition (EMC) exists.
- If an EMC exists, the patient will be stabilized or transferred in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).
- If the hospital has capacity (the ability to accommodate the patient requesting examination or treatment, such as qualified staff, beds, etc.); - If a psychiatric patient has a substantial risk of harming him/herself, or others, or is unable to provide for his/her own food, clothing, shelter, or other essential human needs or that substantial impairment or obvious deterioration of the patient's judgment may result in the patient's inability to function independently, means the patient has an EMC.

2. Review of the facility's Medical Staff Bylaws, revised 12/13/13, showed all Medical Staff Members of the ED and other health care providers with appropriate education, training and experience, or clinical privileges may perform the MSE.

3. Observation and concurrent interview on 04/14/14 at 3:10 PM, showed the main campus ED had 50 beds, six of which were on a unit referred to as "Pod S." Registered Nurse (RN) ED Manager, Staff E, stated that Pod S, a locked unit, was used for psychiatric suicidal (SI) or homicidal (HI) patients, patients on drugs, or patients in police custody. Staff E stated that the main campus ED had access to the BH ED and/or QMHPs from the BH campus across the street, at all times.

4. Review of Patient #28's main campus ED triage record showed that the patient presented, via ambulance, on 03/01/14 at 4:05 AM. The patient was in police custody after having been involved in a fight and stated that, "I'm going to kill myself [SI] and take down a lot of people [HI]." The patient verbally confirmed he was both suicidal (SI) and homicidal (HI). The patient had a history of substance and alcohol abuse, and he was currently positive for alcohol intoxication, cocaine and marijuana use.

Review of Patient #28's laboratory values, dated 03/01/14, showed the patient was currently positive for cocaine and marijuana use, and had an alcohol level of 93 mg/dL (anything above 80 mg/dL is considered high). The patient also had a high level of Creatinine Kinase (CK) of 1,738 IU/L(normal=38-234 IU/L, an elevated level can be indicative of a cardiac problem or many other central nervous system injuries).

Review of physician's orders showed an order for a mental health follow-up related to SI risk dated 03/01/14 at 1:25 PM. The patient had orders to receive nothing by mouth.

The patient received two boluses of normal saline, 1000 milliliters each, and a chemical restraint called Ativan (an anti-anxiety medication) 4 milligrams intravenously at 4:50 AM.

Review of ED physician notes, timed 4:47 AM, 7:30 AM, 8:44 AM, and 1:10 PM, showed the patient would need observation until sober. The patient was violent and a danger to himself and others, requiring chemical and mechanical restraint. The patient had a history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day activities). If the patient's CK level improved, the patient may be discharged home. The patient's CK level did not improve so the ED physician wanted to admit the patient. The patient's admission diagnoses included an altered mental state, drug abuse and an elevated CK.

Review of ongoing Nurses' Notes showed the patient had to be restrained for about four hours, after initial admission, related to aggressive behaviors towards staff. At 4:42 PM, the patient wanted to go home, but was still belligerent with staff. At 5:05 PM, the patient wanted to leave against medical advice (AMA). The patient was discharged, AMA, at 5:10 PM.

Review of the entire ED record showed no documented thorough, overall re-assessment to determine SI risk prior to discharge. The record showed no documented evidence of an alcohol level re-draw prior to discharge. (The facility failed to document if the patient had a home, shelter, or police station to go to, if he was accompanied by anyone such as family, police, etc., or if he could meet his essential needs per their EMC definition and policy).

5. During an interview on 04/16/14 at 2:23 PM, ED Physician, Staff H, stated that when a psychiatric patient with alcohol intoxication presented, they typically got a drug screen and waited until the patient sobered up as the patient usually felt differently about SI/HI. If the ED Physician determined the patient was not at harm toward self or others, and if the patient had a place to go, the patient was discharged. If still SI/HI, a BH evaluation was conducted.

6. During an interview on 04/17/14 at 9:32 AM, ED RN Staff J (triaged Patient #28) stated that the ED physician decided if the patient had a BH evaluation, and when the patient was discharged.

7. During an interview on 04/17/14 at 9:18 AM, ED RN, Staff K (discharged Patient #28), stated that no alcohol level labs were re-drawn on patients prior to discharge to determine sobriety. The ED physician examined the patients for appropriate discharge if SI.

8. During an interview on 04/16/14 at 12:40 PM, Accreditation Officer, Staff A, stated that the facility had the capacity and capability to provide a BH evaluation to Patient #28 on 03/01/14.

9. Review of Patient #43's main campus ED triage record showed the patient presented, via ambulance, on 01/01/14 at 3:27 PM with complaints of a, "Plan to shoot myself [SI], if I had a gun." The patient had a history of depression and had not been taking his anti-depressant medication. The patient's mood was sad and he was intoxicated.

Review of the ambulance record, dated 01/01/14, showed the patient had been depressed for the prior week. The patient told the ambulance crew, "If I could get your gun I'd shoot myself." The patient reiterated, several times during transport he had no reason to live and wanted to kill himself. The patient had previous suicide attempts.

Review of Patient #43's history showed diagnoses of bipolar disorder, alcohol-induced mood disorder with daily alcohol intake, and routine use of anti-depressant medications.

Review of physician's orders, dated 01/01/14, showed an order for a mental health follow-up related to suicide risk. There was no order for fluids or medications.

Review of the ED Physician's note dated 01/01/14 at 3:50 PM, showed the patient had, "No specific plan for suicide so can be d/c'd (discharged) if he recants." Later, at 9:00 PM, the patient denied SI, said he would be safe and wanted to go home. The patient was discharged at 9:14 PM (only five hours later).

Review of the entire ED record showed no documented thorough, overall re-assessment to determine SI risk prior to discharge. The record showed no documented evidence of an alcohol level re-draw prior to discharge. (The facility failed to document if the patient had a home, shelter, or police station to go to, if he was accompanied by anyone such as family, police, etc., or if he could meet his essential needs per their EMC definition and policy).

10. During an interview on 04/16/14 at 12:40 PM, Accreditation Officer, Staff A, stated that the facility had the capacity and capability to provide a BH evaluation to Patient #43 on 01/01/14.

11. During an interview on 4/17/14 at 10:05 AM, ED RN, Staff L stated that, originally, the discharge plan for Patient #43 included sending him for a BH evaluation related to his SI. When the patient recanted his SI, the Physician was notified, and the ED Physician decided to discharge the patient without the BH evaluation.

Staff L stated that it was at the ED Physician's discretion as to the BH evaluation, and condition for discharge. It would also be up to the ED Physician to order a re-draw of alcohol level labs prior to discharge to verify sobriety.

Staff L had no idea of where Patient #43 was discharged to, if anyone accompanied him, or if he drove away, even though the discharge documentation showed he was discharged "home" by "private vehicle. (Contrary to hospital policy, the patient was discharged with no known place to go).

12. During an interview on 04/16/14 at 2:03 PM, ED Physician, Staff I, stated that BH crisis QMHPs were available for patient evaluation at all times. Staff I stated that if a patient was actively suicidal, a BH evaluation was at the discretion of the ED Physician. Staff I stated that she discharged Patient #43 because he was not SI after sobering up and he wanted to go home-she could not keep the patient against his will. Staff I confirmed she had the capability to do a 96-hour hold for a patient's safety. (Even though the facility knew Patient #43 had a history of suicide attempt, and had alcohol-induced mood disorder with daily intake of alcohol, they failed to refer him to BH, a Social Worker or Case Manager that could possibly assist the patient in prevention of a future harm to himself or others).

13. Review of Physician meeting minutes, dated 11/07/13, showed a discussion of a, "a lack of ability to obtain psychiatric consults in the ED." Review of subsequent meeting minutes, showed no action toward this concern.

14. During an interview on 04/16/14 at 3:03 PM, Chairman of the Physician Board, Staff T, stated there was a shortage of psychiatrists and/or psychologists available to provide evaluations to ED patients so they could be determined as safe to be discharged from the ED (rather than waiting in the ED for alternative placement). Staff T stated that this concern had not been revisited, or acted upon since its mention in 11/13.