HospitalInspections.org

Based on interview, review of Intake Assessment and Referral logs, all Triage Evaluation forms for the prior six months, policies, website information, Bylaws, and medical records, the facility failed to:
- Realize their hospital had a dedicated Emergency Department (ED), requiring them to follow Emergency Medical Treatment and Labor Act (EMTALA) regulations from the time their hospital opened to the present.
- Develop a policy and maintain a central log for the purpose of EMTALA.
- Develop an EMTALA compliant policy regarding Medical Screening Examinations (MSEs) within their capability and capacity to determine if an emergency medical condition (EMC) existed for two patients (#25 and #14) of 25 patients' records reviewed from 03/01/17 through 09/19/17.
- Develop an EMTALA compliant policy regarding appropriate transfer out for two patients (#14 and #24) of 25 patients' records reviewed.
- Follow their policy regarding delay in treatment for two patients (#25 and #14) of 25 patients' records reviewed.

Findings included:

1. Review of Centerpointe's current website showed advertising to the public:
-That it provided care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.
- "We are open 24 hours a day, seven days a week."
- "While no appointment is required, it is best to call ahead, if possible."
- "Upon arrival to our hospital, you will be seen by a qualified clinician prior to admission to our facility."

2. During an interview on 09/19/17, at 1:55 PM, Staff A, Chief Executive Officer (CEO), stated that Centerpointe had no ED, did not meet the criteria for EMTALA, and never had in over ten years she had been employed there.

Please refer to the 2567 for more details.

Based on interview and email review the facility failed to maintain records relating to individuals transferred to, or from, the hospital for a period of five years from the date of transfer. This had the potential to affect all patients that presented to the hospital for treatment. The facility census was 99.
Findings included:

1. Even though requested, the facility failed to provide a policy related to transfer of patients from the hospital.

2. During an interview on 09/19/17 at 12:20 PM, Staff A, Chief Executive Officer (CEO), stated that she could not provide the number of patients transferred from the facility as this information was not collected and/or maintained. The CEO stated that patients were transported, not transferred, as they had no Emergency Department (ED); therefore, no emergency transfers. Staff A stated that the ambulance service they utilized would not accept transfer forms from them since they did not have an ED.

3. Review of an email dated 10/02/17, at 12:09 PM, Staff B, Director of Performance Improvement, wrote that the hospital did not maintain records for all patients transferred to, or from, the hospital for a period of five years.

Based on interview, the facility failed to collect, record and/or maintain the required Emergency Medical Treatment and Labor Act (EMTALA) central log for each patient that presented seeking treatment for two (#14 and #25) of 25 patients' reviewed. This failure had the potential to affect all patients who presented. The facility census was 99.

Findings included:

1. Even though requested, a policy regarding maintenance of a central log was not provided.

2. During an interview on 09/19/17 at 3:50 PM, Staff A, Chief Executive Officer, stated that they did not collect and/or maintain a central log that included:
- Patients refusing treatment, or refused treatment;
- Patients transferred;
- Patients admitted and treated; and,
- Patients discharged.
- Facility staff failed to document that Patient #14 was stabilized, transferred to another hospital for medical clearance, then later admitted.
- Facility staff failed to document that Patient #25 ever presented to the hospital requesting care, or that she left without an examination or receiving stabilizing treatment.

3. During an interview on 09/20/17 at 2:23 PM, Staff E, Assessment and Referral (A & R) Supervisor, confirmed Patient #25 presented, and requested care, on 09/11/17. Staff E stated that Patient #25 was not entered into any system/log. Staff E stated she found Patient #25's A & R paperwork in the shred bin, after surveyor inquiry.

4. Facility staff failed to track the appropriate information for all individuals, from their opening date to present, that presented to their facility; therefore, surveyors were unable to select the 20-50 records for review from the information provided.

5. Facility staff failed to provide an accurate count of the number of patients that presented seeking care, or were transferred.

Based on interview, record review, policy review, staff schedule and Physician on-call schedule review, Centerpointe failed to provide an appropriate medical screening examination (MSE) sufficient to determine whether two patients (#25 and #14) of 25 patients' records reviewed had an emergency medical condition (EMC) prior to discharging them.

Patient #25 presented to Centerpointe on 09/11/17 requesting treatment for suicidal ideations (SI-thoughts to harm self). After a partial intake evaluation by the Assessment and Referral (A & R) staff, staff discharged the patient who left the hospital with her fiance'. Approximately twenty minutes later, Patient #25 attempted to jump out of the fiances' moving vehicle, into highway traffic, in an attempt to commit suicide. Patient #25 was transported to Hospital B, via Emergency Medical Services (EMS), and admitted for further treatment of SI.

Patient #14 presented to Centerpointe on 06/05/17 requesting treatment for SI. After the A & R evaluation, staff discharged the patient to Hospital C, via private vehicle, to obtain a medical clearance. The patient was ultimately admitted to Centerpointe for treatment of SI.

Centerpointe's failure to provide an appropriate and sufficient MSE to any individual who presents requesting care could potentially delay treatment to stabilize and increase a patients risk for a negative outcome, including death. Centerpointe's average number of patients evaluated through intake and assessment was 460 per month. The facility census was 99.

Findings included:

1. Review of Centerpointe's policy titled, "Assessing an Emergency," revised 09/10/13, showed the following:
- An EMC was defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The facility should use the criteria for emergency detention under the State Mental Health Code to determine whether such individuals have EMCs. Guidelines include: evidence of mental illness, substantial risk of serious harm to self or others, specific recent behaviors, overt acts, and attempts or threats.
- If the patient refuses to receive further assessment, and A & R staff believe the patient meets criteria for an emergency detention, then the A & R staff member may seek an emergency detention.
- The facility may not delay assessment for an EMC, or stabilizing treatment in order to inquire about the patient's financial resources, including insurance coverage. The facility has a duty to provide sufficient care to stabilize the individual to the extent they are no longer in an emergent state.
- The psychiatric physician is responsible to make the final determination as to whether an emergent condition exists, and make appropriate recommendations for treatment based upon the patient's clinical condition.

2. Review of Centerpointe's policy titled, "Emergency Care," revised 11/12/13, showed the following:
- The A & R staff or outpatient counselors complete an appropriate assessment on clients presenting for evaluation.
- Nursing will evaluate a patient if, during triage or evaluation, a patient's medical/psychiatric status reveals an emergency condition.
- A physician on-call will be consulted.
- The facility will provide treatment consistent with the level of emergency presented, and within the capabilities and capacity of this facility.

3. Review of Centerpointe's policy titled, "Transports from the Facility for Patients and Individuals Being Assessed," reviewed 11/07/16, showed that family may provide transport for non-emergent transports only.

4. Review of Patient #25's A & R Evaluation, dated 09/11/17, showed the following:
- The patient's fiance' drove her to Centerpointe because she was SI.
- The patient was found to be "very suicidal," with a plan to overdose on Xanax (anti-anxiety medication routinely taken) and get into the bathtub. The patient had one previous suicide attempt by overdose.
- The patient was unable to cope with stress, had tremors, loss of appetite, was agitated and irritable.
- The Suicide Behaviors Questionnaire-Revised (SBQ-R), dated 09/11/17, showed it as incomplete, but with a score of 12 (the highest score possible with the questions that were completed). Even though requested, the facility did not provide the parameters (high vs low, and what the scoring indicates) for scoring with this tool.
- The Health Screen was not completed.
- The patient's insurance plan did not include this hospital as an "in network" provider, so the intake evaluation was not fully completed.
- The patient and her fiance' verbally contracted for safety, options for treatment were provided, and the patient was allowed to leave the hospital with her fiance'.
- Even though requested, the facility provided no evidence a comprehensive, appropriate MSE, to determine if an EMC existed, or stabilizing treatment was provided, and/or evaluation for safe transport via private vehicle.

5. Review of the EMS record, dated 09/11/17, showed the following:
- EMS reported to a motor vehicle crash involving Patient #25 and her fiance'.
- The patient/fiance' were struck in the rear while driving on the highway. Patient was enroute to Hospital B for evaluation of depression and SI. Patient's fiance' was driving and stated the accident was caused by the patient attempting to jump from the vehicle to try and kill herself.
- EMS placed the patient on suicide precautions.

6. Review of Hospital B's Emergency Department (ED) record, dated 09/11/17, showed the following:
- Patient #25 presented, via EMS, related to a motor vehicle crash, when she attempted to jump out of the car to attempt suicide while her fiance' was driving on the highway (to go from Centerpointe to Hospital B).
- The patient admitted to being suicidal, prior to arrival, and currently.
- The patient had a past medical history of anxiety, attention deficit disorder (inability to stay on task), manic-depression (depression with highs and lows), cutting behaviors and binge drinking.
- The patient had presented to Centerpointe earlier, but was told her insurance was not valid there, and she may want to go to another hospital (Hospital B).
- The patient was admitted to Hospital B for further evaluation and treatment.

7. Review of Physician on-call schedules showed Staff H, Psychiatrist, was on-call the day/time Patient #25 presented.

8. During an interview on 09/21/17, at 11:20 AM, Staff H, stated A & R staff were to contact the on-call physician for every disposition.The mode of transport for an SI patient depended on risk, if they had active thoughts of suicide, and a plan.

9. Review of Staff schedules showed Staff E, A & R Supervisor, was on duty the day/time Patient #25 presented.

10. During an interview on 09/21/17, at 2:23 PM, Staff E, stated the following:
- The patient was suicidal and bipolar (manic- depression) with a previous suicide attempt via overdose.
- Centerpointe had the capacity and capability to treat this patient.
- The physician on-call was not contacted for evaluation or decision regarding disposition.
- There was no evidence the patient received stabilizing treatment prior to being discharged
- The patient's SBQ-R was not completed prior to the patient leaving the hospital.
- A & R staff did not contact a referring facility/hospital to see if the patient arrived as expected.

11. During a telephone interview on 09/21/17 at 10:40 AM, Staff G, Medical Director, stated the following:
- The A & R staff should do a complete evaluation if the patient was willing to do so.
- The patient should not be allowed to make a decision if they stay if "very suicidal."
- The on-call physician should be contacted for a decision on admission or disposition.
- A "very suicidal," patient should not be sent out with a family member.

12. Review of Patient #14's Client Summary, and A & R, dated 06/05/17, showed the following:
- The patient presented on 06/05/17 at 1:13 PM.
- The patient was in so much physical and mental pain he "doesn't want to live like this anymore."
- He "will kill himself if not able to start feeling well soon."
- He was: anxious, depressed, sad, isolated, helpless, impulsive, suicidal, had poor sleep, had no energy, and experienced weight loss (all can be indicative of depression).
- The patient scored high on the SBQ-R, with a score of 17.
- There was no evidence the on-call psychiatrist was notified for evaluation or disposition decision.
- The patient verbalized a contract for safety, and was transported to another hospital (Hospital C), via private vehicle with his roommate. There was no evidence the patient received stabilizing treatment prior to being discharged.
- Centerpointe had the capacity and capability to treat this patient, and later that day, Patient #14 returned to Centerpointe and was admitted for treatment.

Based on interview, record review and policy review the facility failed to provide a medical screening examination (MSE), and or stabilizing treatment for one (#25) patients of 25 patients' reviewed prior to seeking the individuals' insurance information/authorization. This had the potential to affect all patients that presented to this hospital. The facility's census was 99.

Findings included:

1. Review of Centerpointe's policy titled, "Assessing an Emergency," revised 09/10/13, showed the facility may not delay assessment for an EMC, or stabilizing treatment, in order to inquire about the patient's financial resources, including insurance coverage. The facility has a duty to provide sufficient care to stabilize the individual to the extent they are no longer in an emergent state. The psychiatric physician is responsible to make the final determination as to whether an emergent condition exists, and make appropriate recommendations for treatment based upon the patient's clinical condition.

2. Review of Centerpointe's policy titled, "Emergency Care," revised 11/12/13, showed the following:
- The A & R staff or outpatient counselors complete an appropriate assessment on clients presenting for evaluation.
- Nursing will evaluate a patient if, during triage or evaluation, a patient's medical/psychiatric status reveals an emergency condition.
- A physician on-call will be consulted.
- The facility will provide treatment consistent with the level of emergency presented, and within the capabilities and capacity of this facility.

3. Review of Patient #25's Assessment and Referral (A & R) Evaluation, dated 09/11/17, timed 4:15 PM, showed the following:
- The patient's fiance' drove her to Centerpointe because she was SI.
- The patient was found to be "very suicidal," with a plan to overdose on Xanax (anti-anxiety medication routinely taken) and get into the bathtub. The patient had one previous suicide attempt by overdose.
- The patient was unable to cope with stress, had tremors, loss of appetite, was agitated and irritable.
- The Suicide Behaviors Questionnaire-Revised (SBQ-R), dated 09/11/17, showed it as incomplete, but with a score of 12 (the highest score possible with the questions that were completed). Even though requested, the facility did not provide the parameters (high vs low, and what the scoring indicates) for scoring with this tool.
- The Health Screen was not completed.
- The patient's insurance plan did not include this hospital as an "in network" provider, so the intake evaluation was not fully completed.
- The patient and her fiance' verbally contracted for safety, options for treatment were provided, and the patient was allowed to leave the hospital with her fiance'.
- Even though requested, the facility provided no evidence a comprehensive, appropriate MSE, to determine if an EMC existed, or stabilizing treatment was provided, and/or evaluation for safe transport via private vehicle.

4. Review of the emergency medical system (EMS) record, dated 09/11/17, showed the following:
- EMS reported to a motor vehicle crash involving Patient #25 and her fiance' at 4:28 PM, 13 minutes after the Centerpointe evaluation and/or discharge.
- The patient/fiance' were struck in the rear while driving on the highway. Patient was enroute to Hospital B for evaluation of depression and SI. Patient's fiance' was driving and stated the accident was caused by the patient attempting to jump from the vehicle to try and kill herself.
- EMS placed the patient on suicide precautions.

5. Review of Hospital B's Emergency Department (ED) record, dated 09/11/17, timed 5:09 PM, showed the following:
- Patient #25 presented, via EMS, related to a motor vehicle crash, when she attempted to jump out of the car to attempt suicide while her fiance' was driving on the highway (to go from Centerpointe to Hospital B).
- The patient admitted to being suicidal, prior to arrival, and currently.
- The patient had a past medical history of anxiety, attention deficit disorder (inability to stay on task), manic-depression (depression with highs and lows), cutting behaviors and binge drinking.
- The patient had presented at Centerpointe earlier, but was told her insurance was not valid there, and she may want to go to another hospital (Hospital B).
- The patient was admitted to Hospital B for further evaluation and treatment, at 9:06 PM, or five hours after initial presentation to Centerpointe.

Based on interview, record review and policy review the facility failed to provide an appropriate transfer for two (#14 and #25) patients, with an unstable emergency medical condition (EMC), of 25 patients' reviewed. This had the potential to affect all patients presenting to this facility. The facility census was 99.

Findings included:

1. Review of Centerpointe's policy titled, "Transports from the Facility for Patients and Individuals Being Assessed," reviewed 11/07/16, showed that family may provide transport for non-emergent transports only. For medical emergencies, 911 will be called.

2. Even though requested, the facility failed to provide a policy regarding transfers out of Centerpointe.

3. Review of Patient #25's Assessment and Referral (A & R) Evaluation, dated 09/11/17, showed the following:
- The patient's fiance' drove her to Centerpointe because she was SI.
- The patient was found to be "very suicidal," with a plan to overdose on Xanax (anti-anxiety medication routinely taken) and get into the bathtub. The patient had one previous suicide attempt by overdose.
- The patient was allowed to leave the hospital with her fiance', via private vehicle, to go to another hospital (Hospital B).
- Even though requested, the facility provided no evidence a comprehensive, appropriate MSE, to determine if an EMC existed, or stabilizing treatment was provided, prior to allowing transport via private vehicle.

4. Review of the emergency medical system (EMS) record, dated 09/11/17, showed the following:
- EMS reported to a motor vehicle crash involving Patient #25 and her fiance'.
- The patient/fiance' were struck in the rear while driving on the highway. Patient was enroute to Hospital B for evaluation of depression and SI. Patient's fiance' was driving and stated the accident was caused by the patient attempting to jump from the vehicle to try and kill herself.

5. Review of Hospital B's Emergency Department (ED) record, dated 09/11/17, showed the following:
- Patient #25 presented, via EMS, related to a motor vehicle crash, when she attempted to jump out of the car to attempt suicide while her fiance' was driving on the highway (to go from Centerpointe to Hospital B).
- The patient admitted to being suicidal, prior to arrival, and currently.
- The patient was admitted to Hospital B for further evaluation and treatment.

6. Review of Physician on-call schedules showed Staff H, Psychiatrist, was on-call the day/time Patient #25 presented.

7. During an interview on 09/21/17, at 11:20 AM, Staff H, stated A & R staff were to contact the on-call physician for every disposition.The mode of transport for an SI patient depended on risk, if they had active thoughts of suicide, and a plan.

8. Review of Staff schedules showed Staff E, A & R Supervisor, was on duty the day/time Patient #25 presented.

9. During an interview on 09/21/17, at 2:23 PM, Staff E, stated the following:
- The patient was suicidal and bipolar (manic- depression) with a previous suicide attempt via overdose.
- Centerpointe had the capacity and capability to treat this patient.
- The physician on-call was not contacted for evaluation or decision regarding disposition.
- There was no evidence the patient received stabilizing treatment prior to being discharged

10. During a telephone interview on 09/21/17 at 10:40 AM, Staff G, Medical Director, stated the following:
- The patient should not be allowed to make a decision if they stay if "very suicidal."
- The on-call physician should be contacted for a decision on admission or disposition.
- A "very suicidal," patient should not be sent out with a family member.

11. Review of Patient #14's Client Summary, and A & R, dated 06/05/17, showed the following:
- The patient presented on 06/05/17 at 1:13 PM.
- The patient was in so much physical and mental pain he "doesn't want to live like this anymore."
- He "will kill himself if not able to start feeling well soon."
- He was: anxious, depressed, sad, isolated, helpless, impulsive, suicidal, had poor sleep, had no energy, and experienced weight loss (all can be indicative of depression).
- There was no evidence the on-call psychiatrist was notified for evaluation or disposition decision.
- The patient was transported to another hospital (Hospital C), via private vehicle with his roommate. There was no evidence the patient received stabilizing treatment prior to being discharged.
- Centerpointe had the capacity and capability to treat this patient, and later that day, Patient #14 returned to Hospital A and was admitted for treatment.