HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure a Physician performed a Medical Screening Exam (MSE) to determine whether or not an emergency medical condition existed for one (1) of twenty (20) Patients (Patient # 1).

The findings include:
The ED (Emergency Department) History and Physical dated July 11, 2021 reads in part "Chief complaint - abnormal lab. Patient with pmh (past medical history) sig (significant) for schizoaffective disorder sent from [Name of Facility] for evaluation of an NMDA receptor antibody (N-methyl-D-aspartate receptor is a glutamate receptor and ion channel found in neurons, the primary excitatory neurotrasmitter in the human brain. It plays an integral role in synaptic plasticity, which is a neuronal mechanism believed to be the basis of memory formation.) positive test from a LP (lumbar puncture) 06/25/2012. No change from psychotherapy needs during active [Name of Facility] admission. no allev factors attempted. No clear aggrav factors. No change to the character or severity."

Anti-NMDA receptor encephalitis causes a wide range of symptoms varying in severity. Patients typically start with less severe symptoms, and then rapidly progress to a condition requiring hospitalization. The list below includes the most common symptoms. Most patients with this disease exhibit nearly all of these symptoms; it is extremely uncommon for patients to have only one or two.
Behavior (paranoia, hallucinations, aggression, etc.), Cognition, Memory Deficit, Speech Disorder, Loss of Consciousness, Movement Disorder (rhythmic motions with arms or legs, abnormal movements with the face or mouth), Seizures and Autonomic Dysfunction (www.med.upenn.edu/autoimmuneneurology/nmdar-encephalitis.html)

On June 27, 2022 a review of the grievance logs revealed a statement by the Physician of Patient #1. The Physician stated "Patient had a shaking episode, had some urinary incontinence. [Family Member] was agitated by the Paramedic from the transport service. Asked Paramedic to step away from the Patient. Patient stopped the shaking episode and was immediately responsive, although still as slow to respond as when arrived."

On August 16, 2022 at 11:45 a.m. an interview with Staff Member # 14 revealed the Physician "witnessed Patient # 1 shaking. The episode lasted approximately 15 - 30 seconds. Before the episode occurred [family] was yelling at transport staff were encouraging [family]. [Physician] asked transport staff to step away from patient. [Patient] was immediately back to baseline. There was no postictal state. [Patient] was stable and transferred back to [off site department of the Facility]."
Review of the clinical record for Patient # 1 revealed, the ED Physician failed to evaluate and document in the clinical record a MSE for the shaking episode.

On August 16, 2022 at 2:00 p.m. an interview with Staff Member # 6 revealed there was "no documentation in the clinical record of a shaking episode or evaluation of a shaking episode for Patient # 1 on July 11, 2021."
On August 16, 2022 at 2:30 p.m., an interview with Staff Member # 2 revealed "Peer review revealed Neurology and/or Psychology should have been consulted given NMDA receptor antibodies and mental status changes. Neurology is on call twenty - four/seven and Psychology is on call most days. When the Psychology is not available at the facility, the behavioral health department takes their call."

There was no documented inpatient neurology referral in Patient # 1's clinical record.

The findings were discussed with Staff Members # 2 and # 3 on August 17, 2022 during the exit interview.