HospitalInspections.org

Based on record review and interview the facility failed to ensure that patients at risk for intentional harm to themselves or others were protected in the Emergency Department (ED) prior to discharge or transfer in 2 (Patients # 9, #12) of 3 patient medical records reviewed involving presentation to the ED with chief complaints of suicidal ideations and scored by assessment as a high suicide risk in a total universe of 21 records.

Findings include:
Review of facility Administrative policy on Suicide Precautions, no review/revise dates, revealed, in part, the policy statement, "The Columbia Suicide Severity Rating Scale supports identification of suicide risk through screening and assessments... the answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk and gauge the level of support that person needs." Under the heading 1:1 Suicide Precautions: "Continuous 1:1 visual observation required." "Assessment: "All patients on suicide precautions will be check and documented a minimum of every 15 minutes..use the Meditech suicide intervention."

Medical record review of Patient # 9 revealed a 20 year old patient admitted to the ED with presenting symptoms of "acute onset of self-injurious behavior and hallucinations" on 8/9/2019 at 1:50PM and discharged to law enforcement for transfer to a mental health facility on a Chapter 51:15 hold at 6:50PM. The nursing suicide screening tool revealed patient to be at a high risk for suicide. Review of the medical record failed to reveal documentation of 1:1 nursing observation or suicide precautions taken while the patient was in the ED.

Medical record review of Patient #12 revealed a 61 year old patient admitted to the ED with presenting symptoms of "suicide attempt" on 5/4/2019 at 10:50PM and discharged to law enforcement for transfer to a mental health facility on a Chapter 51:15 hold on 5/5/2019 at 2:17AM. The nursing suicide screening tool revealed patient to be at a high risk for suicide. Review of the medical record failed to reveal documentation of 1:1 nursing observation or suicide precautions taken while the patient was in the ED.

In interview with ED Director A on 11/5/2019 at 11:40AM when asked about suicide precautions in the ED stated, "we use the Columbia scale and all patients who score high must have 1:1 provided - there is an intervention in Meditech that we should be using for documentation." Director A confirmed that this intervention was not present in Patient # 9 or Patient #12's medical record and "should have been."

Based on record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 2 of 11 required areas: Stabilizing Treatment and Medical Screening Exam.

Findings include:

Facility failed to ensure patients who presented to the Emergency Room with an emergency medical condition received stabilizing treatment to ensure patient's safety. See tag 2407

The Facility failed to provide appropriate medical screening exam to determine if a emergency medical condition was present. See tag 2406

Based on record review and interview the facility failed to provide a thorough and appropriate medical screening exam to determine an emergency medical condition in 1 (Patient #1) medical records reviewed in a total universe of 21.

Findings
Review of Patient #1's medical record on 11/5/2019 at 1:20PM revealed admission to the Emergency Department (ED) on 6/1/2019 at 9:59PM with altered mental status. Patient was discharged on 6/2/2019 at 1:30AM with condition at discharge documented as "same". The medical record did not reveal any neurologic assessment on admission by nursing or the medical provider. Workup included labs (including blood alcohol and toxicology, heart tracing, and xray of the head. The record did not reveal any documentation or reassessment of the patient's mental status or neurologic status at discharge. There was no documentation of conversation with the patient's legal guardian before discharge. In interview with the ED Director A on 11/5/2019 at 2:45PM he/she stated, "I would expect to see something that showed if the patient was no longer confused."

Based on record review and interview the facility failed to ensure patients who presented to the Emergency Department (ED) with an emergency medical condition (EMC) received stabilizing treatment and discharge home with discharge instructions to ensure patient's safety in 3 (Patients #8, 11, 16) of 6 patients discharged home in a total universe of 21.

Findings
Review of Patient #8's medical record on 11/5/2019 at 3:20PM revealed admission to the ED on 8/12/2019 at 7:10PM "mumbling incoherent words, visibly psychotic and hyper with flights of ideas." Review of the nursing assessment performed at admission revealed, "...patient only providing incoherent rambling... Lab work including blood alcohol, complete blood count, metabolic panel and toxicology screen were obtained. Review of the nursing assessment under the heading, "Neurological" did not contain any documentation. The provider note under the heading "Psychiatric/Neurologic" stated "...see HPI (history of present illness) anxiety, depressed, emotional problems, pre-existing deficit." There was no documentation of a neurological assessment. Patient was discharged to home on 8/12/2019 at 9:04PM. The medical record revealed in the ED provider note 8/12/2019 at 7:33PM, "the patient was evaluated by the social worker who was very familiar with him she says that he is at baseline with that the patient was reassured and he was discharged to follow-up with his/her regular providers." There was no social worker note and no discharge instructions in the medical record. There was not documentation in the medical record regarding who the patient was discharged with. In interview with ED Director A on 11/5/2019 at 2:45PM when inquired about status at discharge stated, "it would all be in the Crisis workers note, which is not present. We have never required the nurses to document how and with who a patient is discharged."

Review of Patient #11's medical record on 11/5/2019 at 7:40PM revealed a 39 year old patient admitted to the ED on 5/10/2019 at 00:23AM with "hysteria, anxiety, and intoxication." Patient was discharged to home on 5/10/2019 at 6:55AM. Medical record revealed a nurses note at 5/10/2019 at 00:45AM, "phone from (name), crisis worker. Patient has a 2PM appointment with DHS[Department of Health & Human Services] tomorrow." ED Provider note 5/10/2019 at 4:20AM states, "Patient was given Ativan that have helped to calm his/her down. He/she was evaluated by crisis and was given an appointment tomorrow for follow up." There was no crisis worker note in the medical record. There was not documentation in the medical record regarding who the patient was discharged with. Interview with ED Director A on 11/6/2019 at 8:15AM confirmed this documentation was not present and stated, "we expect that anytime crisis is called that they come into the ED, not just a phone consult."

Review of Patient # 16's medical record on 11/6/2019 at 8:20AM revealed a 27 year old admitted to the ED on 7/18/2019 at 5:34PM for "anxiety and hallucinations." Patient was discharged to home on 7/18/2019 at 10:01PM. The medical record revealed in the ED provider note 7/18/2019 at 7:22PM under additional instructions, in part, "follow the plan given to your by the crisis worker." There was not a crisis worker note in the medical record. Medical record revealed the condition at discharge as "same". There was not documentation in the medical record regarding who the patient was discharged with. Interview with ED Director A on 11/6/2019 at 8:40AM confirmed this documentation was not present.