HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures and did not provide stabilizing treatment for one patient with an emergency medical condition (EMC), out of 31 sampled cases from October 2020 through March 2021. Patient #25 presented to the Emergency Department (ED) seeking care for new onset of auditory and visual hallucinations (seeing or hearing things which are not there) that frightened him and made him feel sad. The hospital discharged the patient while he had an EMC, in a taxi cab, alone, to an outpatient behavioral health Rapid Access Unit (RAU) that did not have a physician available and did not have the necessary capability to stabilize his EMC. The hospital's average monthly ED census over the past six months was 5,177.

Review of the hospital's policy titled, "Patient Stabilization in the Emergency Trauma Center," dated 06/16/20, showed:
- All patients determined to have an EMC would be stabilized and patients being transferred or discharged would be stabilized as required under EMTALA obligations.
- Stabilization, with respect to an EMC, means to either provide treatment of the condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during the transfer of the individual from a hospital.
- For purposes of transferring a patient with a psychiatric condition between facilities, the transferring physician would anticipate any reasonably foreseeable complication of that condition and treat immediately prior to transport or provide orders to be carried out in the event of a change in the patient's behavior.

Review of the hospital's policy titled, "In-Patient Admission Criteria," dated 11/12/20, showed that admission to the psychiatric program was indicated for patients above the age of 18 who had psychiatric symptoms, such as hallucinations.

Review of the hospital's psychiatric on-call schedule showed that a psychiatrist was available and on-call to the ED on 03/13/21.

Review of the hospital's inpatient psychiatric unit census for 03/13/21, showed there were five beds available.

Review of Patient #25's medical record for 03/13/21, showed that staff failed to follow the policy and did not provide the patient with stabilizing treatment when he presented to the ED by ambulance with complaints of new onset of auditory and visual hallucinations that scared him and made him feel sad. He stated that it was overwhelming and he was seeking help. He had a history of bipolar disorder (mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), anxiety, depression, and previous history of suicidal ideations (thoughts to harm self). At 12:49 PM, the patient was evaluated by a Licensed Professional Counselor (LPC) and it was recommended that the patient go to the outpatient behavioral health RAU, and the patient was discharged at 2:49 PM per cab to the outpatient behavioral health RAU.

During a telephone interview on 03/24/21 at 3:45 PM, Staff Y, Registered Nurse (RN), outpatient behavioral health RAU, stated that she received a call on 03/13/21 from the hospital ED regarding a patient who had a new onset of hallucinations. Staff Y, RN, stated she told the hospital staff that there was not a provider available and if the patient had a safe place to stay overnight, he should wait and come when a provider was available.

Refer to tag A2407 for further details. Refer to tag A2406 for further details.


39563

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures and did not provide stabilizing treatment for one patient with an emergency medical condition (EMC), out of 31 sampled cases from October 2020 through March 2021. This failed practice had the potential to cause harm to all patients who presented to the Emergency Department (ED) seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 5,177.

Findings included:

Review of the ambulance trip report showed:
On 03/13/21 at 11:20 AM Emergency Medical Services (EMS) was dispatched to the long term care facility (LTC) to transport Patient #25 to the ED due to "new onset of hallucinations (seeing and hearing things which are not there)." At 11:20 AM the EMS crew assessed Patient #25 and began transport to Hospital A.

During a telephone interview on 03/25/21 at 11:42 AM, Staff FF, Emergency Medicine Technician (EMT), stated that the team picked up Patient #25 on 03/13/21 from the LTC and transported him to Hospital A. The patient was very anxious. He told her he was seeing things that he knew were not real. He stated that he heard voices that told him to run away from the EMT but he knew she wanted to help him.

Review of Patient #25's ED record showed:
He was a 63-year-old male with a history of bipolar disorder (mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn't go away) and past history of suicidal ideations (thoughts to harm self). He presented to the ED via EMS on 03/13/21 at 11:53 AM, with a complaint of new onset of auditory and visual hallucinations. He stated he had a history of bipolar disorder that he managed with medications and never experienced hallucinations prior to this episode. He stated that the hallucinations started two days ago and described them as hearing voices and music as well as seeing the building he was in on fire, seeing copperheads, rattlesnakes, and worms that scared him and made him want to run from them. He stated that he felt sad because he saw his mother who was deceased in one of the hallucinations, it was very overwhelming, and he was seeking help. At 2:49 PM the patient was discharged by cab to the Outpatient Behavioral Health RAU.

Review of Staff X, ED Nurse Practitioner (NP), documentation, dated 03/13/21 at 12:08 PM, showed that Patient #25 had a significant psychiatric (relating to mental illness) history which included bipolar disorder and anxiety. Further documentation showed that the patient started experiencing hallucinations two days prior, and indicated he was "hearing voices and music as well as seeing that the building he was in was on fire."

During a telephone interview on 03/22/21 at 11:00 AM, Staff X, NP, stated that the patient presented to the ED with auditory and visual hallucinations. She completed the medical examination and requested a behavioral health professional assess the patient. She did not have any concerns about the patient. She stated the new onset of hallucinations was not a concern considering his medical screening that was completed, but she did feel like the patient would benefit from treatment at the Outpatient Behavioral Health RAU.

Review of Staff R, Registered Nurse (RN), documentation, dated 03/13/21, showed that Patient #25 presented to the ED with complaints of auditory and visual hallucinations. He had a significant psychiatric history of conversion disorder (a mental condition in which a person has paralysis or other nervous system symptoms), bipolar, and anxiety. He denied experiencing hallucinations prior to the current event. He stated the hallucinations started two days earlier and described them as "hearing voices and music and seeing the building he was in on fire." He stated he felt sad because he saw his deceased mother in one of the hallucinations and that it was very overwhelming. Staff R documented that she was notified by Staff V, Licensed Professional Counselor (LPC), that the patient would be treated at an Outpatient Behavioral Health RAU. She stated that the discharge questionnaire showed that the patient lacked decisional capacity evidenced by cognitive (mental process) impairment and had reasonable expectation of imminent harm if discharged.

During a telephone interview on 03/17/21 at 9:15 AM, Staff R, RN, stated that the patient arrived via EMS with auditory and visual hallucinations. She stated that the LPCs usually arranged all appointments with the Outpatient Behavioral Health RAU and they arranged transportation. However Staff V, LPC told her that the RAU would not cover the cost of his transportation and requested the hospital pay for the taxi cab. The supervisor approved the payment and the patient was discharged in the taxi cab.

Review of Staff V, LPC, documentation, dated 03/13/21 at 12:50 PM, showed that Patient #25 told her, "I'm seeing things like snakes, worms, and things that make me wanna run." He stated that he was scared from seeing copperheads and rattlesnakes." Further documentation showed that Staff V, noted that Patient #25 demonstrated depressive symptoms (extreme sadness that doesn't go away), psychotic symptoms (a disorder characterized by false ideas about what is taking place or who one is), visual and auditory hallucinations, excessive worry, his mood was "horrible", and that he had poor insight. At 1:15 PM, Staff V, noted that Patient #25 reported, "he was scared and overwhelmed by his current hallucinations because he had never had them before."

During a telephone interview on 03/18/21 at 4:32 PM, Staff V, LPC, stated that the patient came to Hospital A's ED because he was having auditory and visual hallucinations and he had never experienced that before. She spoke to the Outpatient Behavioral Health RAU and was told there was not a provider available at that time, but one would be available in the morning.

Review of Staff P, ED Physician, documentation, dated 03/13/21 at 1:54 PM, showed her medical decision making and plan of care which included labs to rule out an organic cause (chemical imbalance causing functional disorder) of the patient's hallucinations such as an infection, metabolic disturbance (abnormal chemical reactions in the body), and that a behavioral health assessment was obtained. Staff P further documented that Patient #25 was cooperative, walked in the ED without difficulty, and was not suicidal or homicidal, the patient was safe for discharge and that the mental health evaluator's recommendation was for Patient #25 to go to the Outpatient Behavioral Health RAU. Patient #25 departed the ED with instructions that read, "Go to the Outpatient Behavioral Health RAU from the ED." The discharge instructions did not identify whether an appointment had been arranged or which clinician if any would provide Patient #25 with further examination or treatment upon arrival at the Outpatient Behavioral Health RAU.

During a telephone interview on 03/17/21 at 9:05 AM, Staff P, ED physician, stated that the patient was not a candidate for admission and he stated the patient didn't want to be admitted. The patient agreed to outpatient services and the Outpatient Behavioral Health RAU was an outpatient service that offered same day services. She said she never heard of the Outpatient Behavioral Health RAU not having a provider available and if that was the case she thought they should have sent him back to Hospital A.

The hospital's admission criteria, showed that admission to the psychiatric program was indicated for patients above the age of 18 who had psychiatric symptoms, such as hallucinations.

During a telephone interview on 03/24/21 at 3:45 PM, Staff Y, RN, Outpatient Behavioral Health RAU, stated that she received a call on 03/13/21 from Hospital A's ED regarding a patient who had a new onset of hallucinations. Staff Y stated she told the hospital staff that there was not a provider available and if the patient had a safe place to stay overnight, he should wait and come when a provider was available. Staff Y stated that the patient arrived to the Outpatient Behavioral Health RAU in a cab, and was left standing outside, in front of the facility. She asked the patient if the staff at Hospital A's ED had explained to him that there was no provider available, and the patient said they had not. He stated that he just wanted to get rid of the snakes and worms he was seeing. He was sad when he talked about all the losses in his life and was scared of the snakes he was seeing. Staff Y stated she contacted the LTC facility where the patient resided, and the facility's Social Service Director, Staff W, told her the patient could not return unless he received treatment, and asked Staff Y to send him to Hospital B. Staff Y stated that she called EMT and they came and transported Patient #25 to Hospital B (nearby acute care hospital).

Review of Hospital B's medical record showed that Patient #25 presented to the ED by ambulance and the ED nurse documented at 5:37 PM, that the patient stated he was seeing snakes and worms, and was hearing voices that didn't make sense. Further documentation showed that Patient #25 was admitted to Hospital B's inpatient psychiatric unit for further examination and stabilizing treatment of his EMC.

During a telephone interview on 03/25/21 at 8:00 AM, Staff AA, Hospital B ED physician, stated that the patient had arrived at the ED via EMS and was placed in a psychiatric room due to visual and auditory hallucinations. Staff AA stated that Patient #25 was delusional (false ideas about what is taking place) and psychotic, and would not be safe to discharge. The psychiatric team and psychiatrist all agreed that the patient would benefit from inpatient stabilization.

During a telephone interview on 03/24/21 at 5:30 PM, Staff Z, Hospital B Psychiatrist, stated that Patient #25 needed to be admitted due to his chief complaint of new onset of hallucinations. The patient had been singing to himself and behaving unusual, complained of seeing snakes and worms. He was not safe for discharge due to his mental status, his insight or judgement, and needed a period of stabilization.

During a telephone interview on 03/25/21 at 8:30 AM, Staff BB, Hospital B Psychiatrist, stated that the patient commented at one point that he would rather be dead than keep seeing the snakes and worms. His symptoms could have increased and caused the patient to harm himself. The patient needed help and to be admitted for medication adjustments and stabilization.