HospitalInspections.org

Based on interview and record review, the facility failed to ensure emergency services was delivered in an organized manner.

A. The facility failed to ensure suicide assessments were complete and physician's orders were received for Suicide precautions on 1 of 20 sampled patients (Patient #9).

B. The facility failed to ensure Emergency department (ED) discharge paperwork was completed per their policy in 2 of 20 sampled patients ( Patient #9 and 20).


This deficient practice had the likelihood to affect all patients.



Findings include:



Assessment


Review of the ED notes of Patient #9 revealed she was a 17-year-old female who presented to the ED on 05/04/2021 at 10:02 p.m. Patient #9 was triaged at 10:30 p.m. The following was documented in the triage notes:

"Pt arrives to ED via EMS and Desoto PD for suicidal ideation. Pt is under custody of CPS. Pt was taken to Hickory Trails and was denied there so patient went to sit in the street in hopes of getting hit by a car. Desoto PD showed up and took patient to Dallas Behavior Health and refused to take her due to hx swallowing things. Seen at children's yesterday for vomiting.

Pt is a&o x4, cooperative at this time. CPS at bedside. Pt denies swallowing anything. Scars on forearm from previous self harm."

At 10:31 p.m. the physician documented that Patient #9 complained of suicide ideation. Pt reports that she has thoughts of wanting to hang herself or "overdose on pills"

At 10:36 p.m. a suicide risk assessment was started. The nurse selected that the patient was a behavioral health patient, involuntary, APOWW and sitter. A complete assessment was not documented.

Review of sitters forms dated 05/04, 05/05 and 05/06/2021 revealed Patient #1 was on Suicide precautions and required 1:1 observations. There was no documentation of a physician's order for Suicide precautions on the chart.


During an interview on 05/13/2021 after 11:00 a.m., Staff #'s 3 and 4 confirmed the assessment was not complete and was missing the Columbia Suicide Severity rating scale.


Review of the facility's policy named "Assessment and Management of Suicidal Patient" dated 12/19/18 revealed the following:

"1. Screening for possible suicide or harm to self should be completed on patients with potential risk for suicide per the Columbia Suicide Severity Rating Scale..."

3. Once the patient is identified to be at risk for suicide, a physician or a registered nurse may implement "Suicide Precautions". The nurse should obtain a written order from the physician as soon as possible after implementing the precautions."

Review of a blank Columbia Suicide assessment provided by the facility revealed the following areas should have been addressed:
1. Wish to be dead
2. Suicidal thoughts
3. Suicidal thoughts with method without specific plan or intent to act
4. Suicidal intent without specific plan
5. Suicide intent with specific plan
6. Suicide behavior question
7. How long ago did you do any of these



Discharge Paperwork

05/05/2021

At 1:53 a.m., Patient #9 was medically cleared and the social worker was notified.
At 2:17 a.m., there was documentation that "Per MD, pt is medically cleared and in need of a psych eval"
At 4:01 a.m., a tele psych evaluation was in progress.
At 4:41 a.m., there was documentation that an APOWW was on the chart and dated 05/04 at 10:13 p.m.
At 8:43 a.m. there was documentation that the behavioral health assessor recommended inpatient psych transfer.


05/06/2021

At 10:00 p.m., "Pt stated that when she got out she would kill herself. While speaking with security she threatened to "beat the nurses ass"" jack slap CN so hard it" ll knock her out. 'Threats of harm made multiple times."

At 10:11 p.m., APOWW has expired as of 10 pm this evening and patient requesting to leave the ED. Case worker at the bedside and SW notified as well. Methodist PD present as well.

As of 10:45 p.m. Patient #9 was still on every 15 minute checks for suicidal ideation.

At 11:00 p.m., "CPS Case Worker remains at the bedside and uncomfortable taking the patient back to CPS custody/offices. Methodist PD at the bedside and do not plan to renew APOWW at this time. Patient is standing at the door arguing with staff. I did order her nighttime medications and verified dosages on pill bottles. House supervisor and AOC to be notified as CPS asking to speak with administrative staff."

11:30 p.m. "Pt left after apoww expired."

Physician notes that were signed off at 11:38 p.m., revealed Patient #9 had eloped and was stable.

Review of the record revealed no discharge paperwork nor documentation of an AMA form being signed.


During interviews the following was stated:

During an interview on 05/13/2021 after 3:52 p.m., Staff #6 (ED manager) if a patient is stable the physician does a re-evaluation. If the patient is in their right mind the physician can let them go. They sign out AMA if they are in their right mind. If they not stable the physician has to make the decision and writes the discharge order. Nurses document vitals within an hour of discharge in both cases. If the (unstable) patient refuses to stay they should do the same with the AMA and give discharge instructions.


During an interview on 05/14/2021 at 5:22 p.m., Staff #7 (registered nurse) confirmed Patient #9 was her patient and being present when Patient #9 left the ED. Staff #7 confirmed she did have Patient #9 sign any paperwork nor did she assess her prior to leaving the ED.





Review of the ED record on Patient #20 revealed he was a 14 year old male who presented to the ED on 05/08/2021 at 4:28 p.m. with complaints of watery eyes, swollen eyes and face and an allergic reaction.

Patient #20 was triaged starting at 4:41 p.m..

According to the nurses notes timed for 5:10 p.m., the physician did a brief evaluation on the patient. The recommendation was for Patient #20 to be sent to Fast Track for the remainder of the evaluation and treatment.

At 5:39 p.m., there was documentation that Patient #20's mom was at the nurses station saying they were leaving. The provider was notified.

At 6:08 p.m., there was documentation that Patient #20 eloped.


There was no discharge nor an AMA forms on the chart.



During an interview on 05/13/2021 after 11:00 a.m., Staff #'s 3 and 4 confirmed there was no AMA on the chart.




Review of the facility's policy named "Emergency Medical Treatment and Labor Evaluation" dated 03/22/2016 revealed the following:

"C. Leaving Against Medical Advice (AMA) or Without Being Seen..
2.) Patients who have been evaluated by a physician but have NOT completed the MSE process and request to leave will be identified as requesting to leave hospital AMA.."

Review of the facility's policy named Leaving Against Medical Advice (AMA) dated 12/19/2018 revealed the following:

Leaving AMA does not prevent a licensed practitioner from providing discharge planning or discharge prescriptions as deemed appropriate by the practitioner.

C. Once a patient has requested to be discharged AMA the provider should:

1). Offer the patient further screening, medical exam and treatment and document what further screening, medical exam, and treatment the patient was offered and the patient's refusal.
2). Attempts should be made to obtain and document the reason for the refusal. Inform the patient in writing of the risk and benefits of leaving prior to receiving the recommended screening, medical exams, or treatments.
3). Take reasonable steps to secure written informed consent refusal and document attempts.

D. If the patient appears to be mentally impaired, regardless of the cause (e.g. under the influence of drugs or alcohol, in shock, confused, an /or disorient, etc.) the physician should be notified to allow him/her further opportunity to evaluation the patient prior to the patient being released.

E. If the patient is a minor or otherwise incompetent to sign his release, the request for discharge should be signed by the person legally responsible for him/her. If the patient is a minor and removal from medical care and treatment by the guardian or parent may be life threatening or constitute abuse of neglect, the social worker or Risk Management should be consulted..

F. If a patient is believed to be mentally incompetent due to illness or medications, and/or their departure could lead to harm to the patient or others, his/her departure should be delayed pending consultation with the social worker or Risk Management concerning obtaining court authorization to detain the patient.."

Based on interview and record review, the facility failed to ensure patients presenting to the Emergency department (ED) with a suicidal risk received stabilizing treatment prior to being informed to leave the hospital in 1 of 20 sampled patients (Patient #9).

Patient #9 was still under suicidal watch, not deemed as being psychologically stable by a physician and did not receive stabilizing treatment prior to being informed she had to leave the ED.

Patient #9 left the ED at Hospital A on foot. Patient #9 self mutilated her arm and was taken to Hospital B's ED for care over 1.5 hours later.

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.


Refer to Tag A2407

Based on observation, interview and record review, the facility failed to ensure EMTALA posting in 1 of 2 main patient waiting areas (fast-track waiting area). There was no posting in the waiting area which specified the rights of individuals with respect to examination and treatment of emergency medical conditions, women in labor and whether the facility participated in the Medicaid programs.

This deficient practice had the likelihood to affect all patients who were sent to the fast- track waiting area.


Findings include:


During an observation of the fast- track waiting area on 05/13/2021 at 3:52 p.m., there was no patient rights posting on the walls. There was no posting in the waiting area which specified the rights of individuals with respect to examination and treatment of emergency medical conditions, women in labor and whether the facility participated in the Medicaid programs. Two unidentified people were waiting in the area.

Staff #'s 1,2,3, 5, and 6 confirmed that the area was a waiting area for fast track patients.



Review of the policy named "Emergency Medical Treatment and Labor Evaluation" dated 03/22/2016 revealed the following:

"..9. Signage regarding EMTALA

A. Each MHS facility covered by this policy shall post signs in prominent and conspicuous locations likely to be noticed by all individuals entering ED, L&D, and any other areas where patients are screened (such as entrances, admitting areas, waiting rooms, and /or treatment areas) which, at a minimum, must specify the rights of individuals in accordance of EMTALA.."

Based on interview and record review, the facility failed to ensure patients presenting to the Emergency department (ED) with a suicidal risk received stabilizing treatment prior to being informed to leave the hospital in 1 of 20 sampled patients (Patient #9).

Patient #9 was still under suicidal watch, not deemed as being psychologically stable by a physician and did not receive stabilizing treatment prior to being informed she had to leave the ED.

Patient #9 left the ED at Hospital A on foot. Patient #9 self mutilated her arm and was taken to Hospital B's ED for care over 1.5 hours later.


This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.

Findings include:


Review of the ED notes of Patient #9 revealed she was a 17-year-old female who presented to the ED on 05/04/2021 at 10:02 p.m. Patient #9 was triaged at 10:30 p.m. The following was documented in the triage notes:


05/04/2021

"Pt arrives to ED via EMS and Desoto PD for suicidal ideation. Pt is under custody of CPS. Pt was taken to a private psychiatric hospital and was denied there so patient went to sit in the street in hopes of getting hit by a car. Desoto PD showed up and took patient to a different psychiatric hospital that refused to take her due to hx swallowing things. Seen at an ED yesterday for vomiting.

Pt is a&o x4, cooperative at this time. CPS at bedside. Pt denies swallowing anything. Scars on forearm from previous self harm."


At 10:31 p.m. the physician documented that Patient #9 complained of suicide ideation. Pt reports that she has thoughts of wanting to hang herself or "overdose on pills"


At 10:36 p.m. a suicide risk assessment was started. The nurse selected that the patient was a behavioral health patient, involuntary, APOWW and sitter. A complete assessment was not documented.

At 10:37 p.m., an elopement assessment was performed. There was documentation that Patient #9 had a court -appointed legal guardian or legally committed and was a danger to self or others. Patient #9 had physical or mental impairments that increased her risk of harm to self or others. Patient #9 was deemed as being at high risk for elopement.

At 10:38 p.m., Patient #9 was assessed as having a patient acuity level of 2 (meaning emergent).




05/05/2021

At 1:53 a.m., Patient #9 was medically cleared and the social worker was notified.

At 2:17 a.m., there was documentation that "Per MD, pt is medically cleared and in need of a psych eval"

At 4:01 a.m., a tele psych evaluation was in progress.

At 4:41 a.m., there was documentation that an APOWW was on the chart and dated 05/04 at 10:13 p.m.

At 8:43 a.m. there was documentation that the behavioral health assessor recommended inpatient psych transfer.



05/06/2021

At 9:16 p.m., it was documented "Pt upset that she can't take a shower right now and so she barricaded herself in room by moving bed up against door after being told she couldn't close the door. Security called While pt in barricaded room CPS worker is at bedside."

At 9:20 p.m., Officers pushed through door after pt barricaded it with stretcher, with CPS worker in the room. Pt screaming daring officers to tase her, states that she can be violent, pt states "iv beat people up before"" If nurse comes by here im gonna beat her ass silly"(SIC)

At 9:40 p.m.."Pt taken to shower by security. Situation discussed at length with CN about pt barricading the door with her bed. Bed is to be removed and pt moved to rm 42 with window in door so pt can close it for privacy"

At 10:00 p.m., "Pt stated that when she got out she would kill herself. While speaking with security she threatened to "beat the nurses ass"" jack slap CN so hard it'll knock her out. 'Threats of harm made multiple times."

At 10:11 p.m., APOWW has expired as of 10 pm this evening and patient requesting to leave the ED. Case worker at the bedside and SW notified as well. Methodist PD present as well.

As of 10:45 p.m. Patient #9 was still on every 15 minute checks for suicidal ideation.

At 11:00 p.m., CPS Case Worker remains at the bedside and uncomfortable taking the patient back to CPS custody/offices. Methodist PD at the bedside and do not plan to renew APOWW at this time. Patient is standing at the door arguing with staff. I did order her nighttime medications and verified dosages on pill bottles. House supervisor and AOC to be notified as CPS asking to speak with administrative staff."

11:30 p.m. "Pt left after apoww expired."

Physician notes that were signed off at 11:38 p.m., revealed Patient #9 had eloped and was stable.

Review of ED notes from Hospital B revealed Patient #9 presented there at 05/07/21 at 1:19 a.m..( over 1.5 hours after leaving Hospital A). The following was documented in the ED notes:

"17-year-old female presents to the emergency department via police custody with suicidal ideation and cutting her left forearm. Patient with multiple suicide attempts psychiatric illness. Recently was in an outside hospital and was being held. Her 48 hour hold expired at 2330 (11:30 pm) this evening. She was being taken out of the hospital by her caseworker and started cutting her arm. They called 911 and they brought her to the emergency department. She is nonverbal at this time not talking."

On 05/07/21 at 2:57 a.m., Patient #9 was transferred and admitted into Hospital C for psychiatric care.


During interviews the following was stated:

On 05/13/2021 after 3:52 p.m., Staff #6 (ED manager) stated if a patient was stable the physician does a re-evaluation. If the patient was in their right mind the physician can let them go. They sign out AMA if they are in their right mind. If they were not stable the physician had to make the decision and writes the discharge order. Nurses documented vitals within an hour of discharge in both cases. If the (unstable) patient refused to stay they should do the same with the AMA and give discharge instructions.

On 05/13/2021 at 4:42 p.m., Staff #14 (social worker) stated that if the APOWW was expired they had to let the doctor know. It only last for 48 hours excluding the weekend. There was no legal hold on the patient. If police wouldn't renew the APOWW the physician could ask for another evaluation. Another option was that the family could issue a white warrant.

On 05/14/2021 at 12:04 p.m., Staff #8 (physician) stated she remembered the case. Patient #9 had been there waiting on placement. Staff #8 stated she was the last doctor on the case. Patient #9 was on an APOWW and it was going to expire that evening. Staff #8 saw the patient after she had barricaded herself in the room. A caseworker, sitter, nurse and 3 police were in the room and the tensions or frustration were high. Patient #9 was at the door and verbally cursing. Patient #9 said she had not received her night meds. Staff #8 (physician) stated she ordered the meds Patient #9 needed and thought that appeased her. The caseworker in the room said she was frustrated about the placement. Staff #8 (physician) stated that a police officer told her that the hospital could not physically keep the patient because her APOWW had expired. Staff #8 (physician) stated she left the room and later on a nurse told them that Patient #9 had walked out.

Staff #8 (physician) stated that she had documented in the discharge area that Patient #9 was stable. When asked what that meant? She stated that meant she was physically stable. Staff #8 (physician) stated that she did not discharge her because she did not have enough information. The police department asked if she could discharge her and they were told she couldn't see that they could do that. The guardian (CPS worker) didn't feel comfortable with the patient either. Staff #8 (physician) said to her Patient #9 wasn't violent or physical.

During an interview on 05/14/2021 at 5:22 p.m., Staff #7 (registered nurse) stated that she started her shift at 7:00 p.m. that night (05/06/2021) and that Patient #9 was her patient. Staff #7 (registered nurse) said Patient #9 got upset because they could not help her get a bath. Patient #9 pushed her bed up against the door and said she wanted to have a personal conversation with her CPS worker. The patient was informed she couldn't do that. The charge nurse talked to the police and said her APOWW was expired and she couldn't have her threatening her staff. The charge nurse asked the police if they were going to renew the APOWW and they said no. Staff #7 (registered nurse) said the police asked her if she wanted to press charges and she didn't. Staff #7 (registered nurse) stated that Patient #9 said to give her clothes to her and she would go to her mom's. Patient #9 then turned to the CPS worker and asked if she would give her a ride. The CPS worker did not answer. Patient #9 got dressed and asked where was her paperwork. Staff #7 (registered nurse) told Patient #9 since she was leaving without the doctor discharging her that she didn't get any paperwork. Staff #7 (registered nurse) stated that Patient #9 left out of the emergency room. On her way out of the ED the CPS worker said that all of that was on Staff #7 (registered nurse) and that she had to go and take care of Patient #9. Staff #7 (registered nurse) said the physician said she was not discharging Patient #9, but she was free to leave. When asked if Patient #9 was still on suicide precautions Staff #7 (registered nurse) said the doctor had not written an order discontinuing it.

During an interview on 05/17/2021 after 12:05 p.m., CPS #19 stated that she was the person on duty that night in Patient #9's room. CPS #19 confirmed that Patient #9 got upset over not being able to get a shower. After the incident with the bed and them moving Patient #9 to another room Staff #7 (registered nurse) came into the room and said we had to go because her APOWW had expired. CPS #19 said the nursing staff were telling her she had to leave and that they were printing off AMA forms. The police officers were telling us we had to leave or they would call Dallas PD and they could charge us with trespassing. CPS worker #19 said Patient #9 walked out and she kept following the patient in her car. Patient #9 was on foot. Somehow Patient #9 cut herself. CPS worker #19 called the police and they reported Patient #9 as a runaway. CPS worker #19 said her co- worker was able to talk Patient #9 into her car and they took her to Hospital B for care.




Review of facility's "Medical Staff Policy Manual" signed by the board on 03/23/2021 revealed the following:
". It is the policy of Methodist Health (MHS) hospitals to comply with the Emergency Treatment and Active Labor Act (EMTALA). EMTALA requires that any patient who presents at the Emergency Department (ED) must receive an appropriate medical screening examination to determine if that patient has an emergency medical condition. If so and except as authorized under EMTALA, the patient's condition must be stabilized prior to transfer..."

"..Stabilize means: with respect to an Emergency Medical Condition, to provide such medical treatment of the condition as may be 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 facility, or, with respect to an Emergency Medical Condition involving a pregnant woman, that the woman has delivered (including the placenta).."






Review of the facility's policy named "Involuntary Detainment of Behavioral Health Patients" dated 03/14/14 revealed the following:

"POLICY:
1. Methodist Health System will provide stabilization and arrange for the transfer of patients meeting criteria for involuntary detainment for the purposes of Behavioral Health evaluation and/or treatment.
GUIDELINES:
3. Once the mental health assessment is completed and the recommendation either from the mental health professional or the physician is to pursue involuntary detainment the following should be used to provide direction to the staff.
A. There was two options to legally detain a patient involuntary for the purposes of Behavioral Health evaluation and/or treatment.

1. Emergency Detention
a) The intent of Emergency Detention is to take a person into custody in order to perform an initial/preliminary exam by a physician (does NOT have to be a psychiatrist) to determine the need for involuntary admission to a mental health facility..
b) Can be initiated by a peace/police officer which does not require processing through the mental illness court or obtaining a warrant (Notification of Emergency Detention)..pursued when:
f) Emergency Detention should be pursued when:
1.The patient meets the criteria for detainment, AND

11. The situation is emergent and there is not time to pursue an Order of Protective Custody (e.g. suicidal patient in the emergency department at 2am, or a psychotic patient that abruptly started acting out on an inpatient unit that can no longer be safely maintained)
2) Order of Protective Custody
a) The intent of a motion for an order of protective custody is to legally authorize the detainment of a patient until a hearing to authorize court commitment for up to 90 days of mental health treatment can be held ..

..4. The criteria for involuntary detainment of a patient (regardless of which option is utilized to authorize the detainment) as is follows:
A. The applicant, based on direct observation or reliable report, has reason to believe the patient is mentally ill, AND
B. The patient must exhibit a substantial risk of serious harm to self and/or others either by recent behavior, overt acts, attempts, or threats that have been observed, AND
C. The risk of harm must be imminent unless the person is detained and less restrictive measure must not be available, OR
D. There is evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person can not remain at liberty, AND
E. The patient has refused voluntary mental health treatment.
5. Common examples of behavior in which involuntary detainment may be required include but are not limited to:
A. Suicide attempt, gestures or self-mutilation
B. Threats of suicide or suicide ideation.."