HospitalInspections.org

Based on policy review, Medical Staff rules and regulations, medical record review, review of credentialing files and interview, it was determined the facility failed to ensure all patients presenting to the Dedicated Emergency Department (DED) received an appropriate Medical Screening Examination (MSE) within the hospitals capabilities to determine if a medical or psychiatric medical emergency existed in order to ensure all emergency psychiatric conditions were treated and patients stabilized for 3 of 25 (Patients #5, #24 and #7 ) sampled patients.

The findings included:

1. Review of the hospital's policy, "Evaluation and Transfer of Patients with Emergency Medical Conditions Including Pregnancy with Contractions", documented, "...Emergency Medical Condition...Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing health of individual (or with respect to pregnant woman, health of woman or unborn child) in serious jeopardy, 2. Serious impairment of bodily functions, or 3. Serious dysfunction of any bodily organ or part; or ...To stabilize/stabilize...The term "stabilize" means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition described above ...Policy: I Medical Screening ...C. Persons requesting examination or treatment from medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions ...E. The initial medical screening and treatment includes the use of necessary ancillary services routinely available at [name of hospital] emergency department or L&D [labor and delivery]. II. Scope of Responsibility
A. If patient is determined to have an emergency medical condition as defined above, further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient ..."

2. Review of the "Rules and Regulations of the Medical Staff of (name of hospital) documented, "3.6-2 GUIDELINES FOR CALL CONSULTATIONS Unless the attending practitioner's expertise is in the area of the patient's problem, consultation with the qualified medical doctor is required in the following cases: (a) A patient known or suspected to be suicidal..."

3. Review of the facility policy, "Suicide Assessment/Precautions Policy" documented, "...12. Collaborate with physician to determine level of observation and obtain order as soon as possible: a. Possible Suicide Risk 1) Indications: expressing vague suicidal ideation without a a plan; no demonstrated self-destructive behavior; chronic suicidal thoughts. 2) Observe every 30 minutes for patient safety. 3) Initiate frequent verbal contact. b. Serious Suicide Risk 1. Indications: patient admitted following suicide attempt verbalizes intent to harm self; has concrete/specific plan; exhibits disorganized and/or psychotic behavior; also indicated for medically stabilized patient following recent suicide attempt. 2. Continuous observation (hospital or contracted personnel). 13. Discuss psychiatric services and appropriate setting for treatment with physician/health team members"

4. Medical record review for Patient #5 revealed on 1/15/2010 at 2:51 PM the patient arrived at the DED via Emergency Medical Services (EMS) with a chief complaint of attempted suicide by hanging himself with a sheet. DED Physician #1 examined the patient on arrival and initiated a MSE documenting the patient, "...hung self (tried) but sprinkler he tied sheet to broke ...psych problems ...situation problems 'in prison'..." The physician further documented on the hospital's T-System Documentation Guidelines form the patient had past history of psychiatric problems and bipolar disorder. Under the physical exam section the physician documented, "Psych depressed, suicidal." The documented clinical impression was "suicide attempt." The section on the T-System form for Medical Clearance for Psychiatric Referral was left blank. There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed. The patient did not receive every 30 minute suicide checks while in the DED. The patient was discharged back to prison at 5:56.

Review of the Tennessee Department of Correction Referral for Emergency Care form sent back to prison with the patient documented, "Current Complaint/Patient History: I/M [inmate] found hanging in cell-unknown amount of time-upon arrival of nurse I/M on floor c [with] blood coming from mouth-difficulty breathing ... REPORT FROM OUTSIDE FAC [Hospital DED] ...Treatment given: none. CT [computed tomography] - no bony or obvious soft tissue injury...Pt needs to be on suicide watch, See PCP [primary care physician] if any throat or neck symptoms and have psych eval [evaluation]." This form was signed by DED Physician #1.

Review of the credentialing file for DED physician #1 revealed the physician's area of expertise was Family Practice Medicine. There was no documentation the physician was qualified to determine if an emergency psychiatric condition existed.

5. Medical record review for Patient #7 revealed the 32 year old presented to the DED on 1/22/10 at 3:40 PM via ambulance following a motor vehicle accident (MVA). Review of the Ambulance Patient Care Report documented, "...Pt [patient] stated he wanted to die..."

Review of the hospital's T-system Emergency Nursing Record for MVC documented the patient was triaged at 3:40 PM with a chief complaint of head and neck pain, lt (left) hip pain. The nurse also documented, "Pt states if he goes to jail he will beat himself to death. Pt extremely belligerent, in cuffs" Review of the T-system Emergency Department Record noted the patient was seen on arrival by DED Physician #1. Review of the Psych section of the T-system form documented mood and affect was circled, indicating an affirmative. Progress notes written by DED Physician #1 documented, "pt intoxicated... Pt made suicidal statement to nurse (though not to me)... Transferred care to Dr. [physician #2] [illegible mark] labs, response to Rx [prescription]. If dc' d [discharged] to jail, place on suicide precautions with psych eval stat per protocol" Physician #1 documented the clinical impression was "suicidal ideation, MCV [motor vehicle collision] and polysubstance abuse."

Review of the T-system Emergency Department Record revealed the patient was examined by the Family Nurse Practitioner (FNP) at 1800 (6:00 PM). Under the psychiatric physical exam section of the T- System form, the FNP documented the patient was "sleepy." The progress notes revealed the patient had, "slurred speech. can't stay awake long enough to answer questions. groggy Narcan 2 mg"

At 6:10 PM the FNP ordered a Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP), urine drug screen and Alcohol (ETOH). Review of the lab results revealed the patient was positive for cocaine, opiates and benzodiazepine and negative for alcohol.
A CT of the head documented sinus disease. The CT of the neck was normal.

At 7:15 PM, the FNP documented, "Will awake to verbal stimulation very combative during catheterization" The FNP documented the clinical impression was, "...polysubstance abuse." A disposition order at 7:15 PM documented, "sent to [named county jail] with sheriff's deputy" There was no documentation of the patient's condition at discharge by the FNP. An un-timed progress note by the FNP dated 1/22/10 documented, "Given transfer sheets to [names deputy sheriff]. He is to be on suicide precaution with q [every] 15 " [minute] [abbreviation for checks]. He is also to be closely observed due to polysubstance abuse. He did not verbalize suicidal ideations or depression. He states, 'I'm pissed because I have to go to jail'. Able to awaken with stimulus"

A Prisoner Medical Clearance Report dated 1/22/10 and signed by DED Physician #2 documented, "I have examined the prisoner [patient] and find him/her acceptable for admission to the jail providing the following conditions are met. Suicidal precautions q 15 minute checks" There was no documentation of discussion or referral to the hospital's inpatient psychiatric services, outpatient psychiatric services, mobile crisis or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed. There was no documentation the patient was on every 30 minutes suicide checks while the patient was in the DED.

Review of the transfer sheet signed by Physician #2 revealed a diagnosis of Polysubstance Abuse. There was no documentation of suicide risks, prevention, counseling, or a psychiatric evaluation or referral.

Review of the credentialing file for physician #2 revealed the physician's area of expertise was Ophthalmology. There was no documentation the physician was qualified to perform a psychiatric evaluation to determine if an emergency psychiatric condition existed.

On 1/23/10 at 5:31 PM Patient #7 was transferred from the jail back to the DED for attempted suicide by hanging. Upon arrival to the DED the patient was intubated, pupils fixed and dilated with ligature marks around the neck, and had urinated and defecated in his pants. A MSE was performed at 5:45 PM and the patient was transferred via helicopter to another hospital for a higher level of care.

Review of the Chief Medical Examiners report dated 1/24/10 revealed the patient expired on 1/24/12. The cause of death was suicide.

6. Medical record review for Patient #24 documented an admission to the DED via police custody on 1/24/10 at 5:00 AM for possible drug ingestion. Review of the Emergency Department Record documented the MSE was initiated at 5:40 AM. The suicide risk assessment was deemed low risk. The chief complaint was substance abuse agent unknown and anxiety. The clinical impression was, "Substance abuse." A Urine Drug Screen was positive for amphetamines, opiates and tetrahydrocannabinol. The ExitCare Patient Information form (discharge instructions) documented Physician #2 was the attending physician in the DED and the patient had no regular primary care physician. The patient was discharged at 6:09 AM with condition unchanged and in the custody of the sheriff. There was no documentation of discussion or referral to the hospital's inpatient psychiatric service, outpatient psychiatric services, mobile crisis, or a psychiatric evaluation by a qualified member of the Medical Staff to determine if a psychiatric emergency condition existed.

7. As a comparison, medical record review was completed for Patient #16 which documented an admission to the DED via ambulance on 12/31/09 at 1010 AM after a suicide attempt at home via hanging. Documentation on the Emergency Nursing Record revealed the sheriff's deputy stated the patient was unresponsive upon his arrival at the patient's home, and CPR was initiated with response. DED Physician #1 ordered a mobile crisis evaluation to be performed in the DED. The mobile crisis team recommended the patient be involuntary admitted to the state mental hospital. DED Physician #1 discharged the patient and had him transferred to the state mental hospital for admission . While the patient was in the DED, every 30 minute close observation checks were performed.

8. During an interview in the administrative conference room on 7/9/12 at 3:00 PM, the Risk Manager was asked about Patient #7's treatment in the DED and why a psychiatric evaluation was not completed. She stated, "...may have asked for a psych eval to be done at the jail ...sometimes that happens if [patient] in police custody ...once he got to jail ...have a psych eval ..." When asked if the facility would have normally done the evaluation at the DED, she stated, "Yes, and I think that is our protocol now ...[physician] order sheet no I believe has basic psych eval listed on it ..." The Risk Manager then pulled an Emergency Department Order Sheet and verified the consult had been added as an option for DED physicians to order. When asked when the facility identified the problem, she stated, "Immediately ...after he [patient #7] came back in ...hanged self ..."

During an interview in the administrative conference room on 7/11/12 at 10:10 AM, the Chief Nursing Officer was asked what are the expectations in the DED if a patient is suicidal? She stated she would expect to see documentation of a risk assessment, intent, plan, past attempts, removal of clothing articles, belts and straps, and 1:1 or close observation. If the nurse disagrees with the discharge plan or has concerns she would expect the nurse to follow the chain of command. She stated there had been a lot of education concerning this. She further stated patients who are prisoners at the correctional facility have their own medical facility and psychiatrist. The patients get general clearance at the hospital, and are sent back with the expectations of follow-up with a psychiatrist at the prison.

During an interview in the administrative conference room on 7/10/12 at 11:45 AM, the Emergency Medical technician (EMT) #1 was asked if Patient #7 expressed suicidal ideations while being transported to the DED on 1/22/10. EMT #1 was given the Ambulance Patient Care Report he completed on 1/22/10 to review. EMT #1 stated, "...statement was made when we were in route to the hospital ..." EMT #1 verified that Patient #7 made a statement that he would kill himself. He further stated, "I went to school with him ...I said (naming Pt #7] you don't want to do that ...he calmed down, but I put it on the ticket [Ambulance Patient Care Report] because he said it to me ...I reported it when I gave report [to nurse at DED] ..."

During an interview in the administrative conference room at 1:00 PM on 7/11/12, the Director of Clinical Risk Management and Medical Staff Coordinator verified there was no evidence on the physician's Delineation of Privileges that addressed psychiatric care. The Director of Clinical Risk Management stated, "If they are going to do psychiatric evaluations, I would expect to see it."

During a telephone interview on 7/11/12 at 2:10 PM Physician #1 was asked what the procedure was if a patient expressed suicidal ideations? Physician #1 stated, "Monitor setting, rule out medical or emergency situation and consult a psych" The physician was asked if there was a different procedure for patients that are in custody of law enforcement. Physician #1 stated, "Yes, prison/jail system has procedures in place for prisoners. We medically clear them in the ER [emergency room], or could get crisis consult, then send to jail for suicide precautions and they consult psych. The crisis teams are familiar with jail"