HospitalInspections.org

Based on policy review, hospital internal call log review, medical record review, staff and physician interviews, hospital personnel file review and contact sheet review, the hospital failed to comply with 489.24 by failing to provide an appropriate medical screening examination for 1 of 10 sampled patients presenting to the hospital's behavioral health dedicated emergency department (#7).

The findings include:

~cross refer to Tag A2406

Based on policy review, hospital internal call log review, medical record review, staff and physician interviews, hospital personnel file review and contact sheet review, the hospital failed to provide an appropriate medical screening examination with ongoing monitoring for a patient with an emergency medical condition in 1 of 10 sampled patients presenting to the hospital's behavioral health dedicated emergency department (#7).

The findings include:

A review of the hospital's policy "Emergency Department Assessment Procedures, Policy ED-37" (revised 10/2009) revealed "When a patient presents for evaluation, an assessment will be completed. Psychiatric evaluation are performed 24 hours a day, 7 days a week. Assessments are performed by the Registered Nurses (RN) or master's prepared clinician in conjunction with the physician and/or extender. The Emergency Department (ED) physician or extender will complete the mental status exam and diagnostic impression. Reassessment: Reevaluation of current suicidal/homicidal ideation and also past danger to self and/or others." The policy further revealed that the physician/physician extender summarizes the need and conclusion for treatment and the appropriate level of care.

A review of the hospital's policy "Duty To Protect Or Warn, Policy CA-6" (revised 01/2010) revealed that the organizational group of physicians, nurses and therapists will "exercise best professional judgement to protect the lives and physical safely of our patients and of any known potential victims of possible imminent violence." The policy review further revealed that "When, during the course of an assessment or therapy, a professional learns that there is a clear and imminent reasonable foreseeable danger of harm by a patient to a known specific victim, including another staff member, the therapist should:

A. attempt to dissuade the patient;
B. consider alternative therapeutic measures such as hospitalization;
C. consult with the Department Head and, if appropriate, notify the police and intended victim; and
D. clearly document all such incidents and notify Administration and Risk Management."

A review on 04/14/2010 of the hospital's behavioral health call center contact log revealed that Patient #7 contacted the call center on 02/28/2010 at 1550 with a presenting problem of being "homicidal." The documentation of the patient's complaints revealed that the patient "argues a lot with wife and having thoughts of harming wife." The documentation also revealed that the patient had thoughts of harming animals and some issues with past alcohol abuse. The documentation by the staff revealed that the patient was instructed to come to the behavioral health emergency department for an ED Evaluation.

A review 04/14/2010 of the closed medical record for Patient #7 a 33 year old male, revealed that the patient presented to the hospital's behavioral health dedicated emergency department on 02/28/2010 at 1806 (two hours and 16 minutes after calling call center) with a complaint of "Depressed reference fighting with his wife." Documentation by the patient on the hospital's form "Emergency Department Patient Information" at the time of presentation to the hospital, revealed that the patient documented his reason for coming to the ED as "Im feeling depressed and I feel like hurting someone or myself. Ive been fighting with my spouse a lot and words that she said to me that have made me angry. I want to talk to someone about my mental status."

Documentation of the hospital's triage RN on 02/28/2010 at 1828 revealed that the patient stated his complaint as "Feeling depressed and is going through a divorce from his wife. He has his 10 year old child here with him and states he doesn't have anyone that (to) come and watch her while he is being assessed. He states he has a lot of pent up anger and in the past he has had homicidal ideation. He denies current suicidal/homicidal ideations or auditory/visual hallucinations." The documentation of the risk assessment by the triage RN revealed that the patient did have access to firearms/weapons by stating that the patient "Has a rifle and a 45."

The review of the patient's assessment by a RN (RN #1) revealed in the ED Detailed Assessment Form that the patient "presents with request of "I need some help" new to area and "wants to get into the system" Reports history of depression and denies current suicidal/homicidal ideations and auditory or visual hallucinations." The documentation from RN #1 revealed that the patient did have access to firearms that were "locked up."

An interview with RN #1 on 04/14/2010 at 1429 revealed that she did not remember the patient at all. The interview revealed as the nurse reviewed her charting in the patient record that the patient did have weapons locked up at home. No other information was remembered about the patients treatment on 02/28/2010.

Documentation of the mental status examination by the ED physician treating the patient on 02/28/2010 revealed that the patient's mood and affect was "somewhat depressed" with his insight and judgement impaired." The documentation by the physician revealed that the patient voluntarily requested treatment for depression and a chronically volatile relationship with his wife that included verbal and physical conflict from both of them. The ED physician further documented that the patient had no suicidal or homicidal ideations and was discharged to home at 2002 with prescriptions given for medications Citalopram (antidepressant medication) 20 milligrams daily and Buspirone (antianxiety medication) 10 milligrams twice a day for 2 weeks. The patient was also instructed to follow up as an outpatient in the behavioral health clinic by calling the next day for an available appointment.

An interview with the treating ED physician for 02/28/2010 via telephone on 04/14/2010 at 1510 revealed that the physician did not remember the patient. The interview revealed that the physician was told of the patient related to a "Bad outcome" later and stated based on the physician documentation that the patient denied suicidal and homicidal ideations before being discharged. Interview revealed the patient did have depressed mood and he was given prescription for new medications along with information to schedule appointments for outpatient care. Interview revealed the physician felt the patient was ok for discharge.

Further record review revealed Patient #7 returned to the hospital's behavioral health dedicated emergency department for a second visit on 03/16/2010 at 0215 with a complaint of "wanting to hurt his wife." Documentation by the patient on the hospital's form "Emergency Department Patient Information" at the time of his second presentation to the hospital, revealed that the patient documented his reason for coming to the ED as "Harm somebody." The patient also documented that he expected "help" and "Therapy" from the visit to the hospital on the form.

A review of the ED triage form documented by RN #1 at 0243 revealed that the patient was triaged as "urgent" and with a stated complaint "When patient first arrived he told the registrar that he wanted 'to kill my wife'. After search and in triage he denies that he wants to kill her but 'I'm tired of the BS.'" Review of the triage form revealed "diagnoses (Active) as Homicidal Thoughts". Documentation in the risk assessment section of the triage form revealed that the patient denied homicidal ideations and had access to firearms/weapons with the details documented as "Have safety locks on them." The documentation also revealed that the patient had visual hallucinations documented as "I see shadows of people every day but I don't ever hear any voices."

Review of the hospital's ED Detailed Assessment form for 03/16/2010 revealed that RN #1 documented the patient had sad mood with thought processes coherent, logical goal directed with orientation to person, place, day/time and situation. Documentation of the reason for visit revealed "I want to kill my wife". The documentation by RN #1 further revealed "Later during triage he denies it, but stated he was tired of her BS. Reports that they were arguing this evening. Reports he was here 2 weeks ago and meds are helping some. Denies suicidal ideations, auditory hallucinations. Admits to visual hallucinations, 'I see shadows of people everyday.'" The documentation under the risk assessment section for (Danger to Others) revealed "Homicidal Ideations as (NO) with comment was earlier."

An interview with RN #1 on 04/14/2010 at 1429, in reference to the patient's hospital visit on 03/16/2010, revealed that again she did not remember the patient, only her notes about the the visit. While reading her notes, the nurse in the interview revealed that the patient did deny homicidal ideations to her after previously admitting to them to the registration person. The interview revealed that she did not talk or discuss any details with the registration person that heard the comments. The interview also revealed that no tests such as alcohol or drug screening were done for the patient, but she did state that no alcohol or drugs were detected or thought to be a problem. While reading her notes, the nurse in interview revealed she did not notify the patient's wife or the police of the patient's threats to harm his wife. Further interview revealed the nurse had just started working at the behavioral health hospital in early February 2010. Interview revealed the nurse was no longer on orientation, but she was not sure whether or not she was still on orientation on 03/16/2010.

Documentation by the ED physician for 03/16/2010 signed at 0445 revealed that the patient had mood and affect as euphoric mild to moderate with judgement decreased but adequate. The documentation by the ED physician revealed that the patient "Reported homicidal ideations to coordinator earlier, now denying saying 'I just had to get out.' Here in 02/2009 (incorrect, per hospital visits was 02/2010) for same. Notes under therapy initiating soon. Has spoken of marital therapy and now will pursue this. Endorses capacity to refrain from harm to self and others." The documentation revealed that diagnosis for the patient was "Depression NOS." Condition at discharge was documented as "stable, home by self with discharge instructions to keep other appointments with an increase in Buspar (no dosage documented)."

An interview on 04/14/2010 at 1413 with the ED physician that treated the patient on 03/16/2010 revealed that he did not remember the patient. He reported that he was told of the outcome and referenced the patient's negative outcome. The physician revealed that based on his documentation he described the patient being here in 2009 (although when asked he did reveal that the documentation was in error and was actually 2010 when the patient was at hospital). The interview revealed that the patient was screened and he felt was okay to return home for marital therapy. The physician also revealed no medications or lab studies were done for the patient. The physician also stated that he reviewed all of the nursing documentation and made the choice to send the patient home. The physician also revealed that there was no need, in his judgment, to warn or notify the patient's wife or police of the patient's threats to harm his wife. Interview revealed, "I did not feel it was needed." The interview also revealed that the physician would not have done anything different if the situation presented again. Interview revealed, "I think under the circumstances and the situation at the time, I would not have changed therapy or treatment for the patient."

A review of the discharge notes for the patient in the closed medical record dated 03/16/2010 revealed that the patient was discharged to home at 0535. The documentation by the nursing staff revealed, "Home instructions discussed. Questions and concerns addressed. Discharged to home self-care."

A review of RN #1's personnel file on 04/15/2010 revealed that the section of "Orientation Schedule and Preceptor Guidelines" had documentation the nurse was hired on 02/01/2010 (one and a half months before the nurse the patient was discharged to home on 03/16/2010). The document had checklist for the training expectations of the nurse. The review further revealed that the document had a section statement of "I have reviewed and completed the above checklist. I understand that I am now considered to have completed oriented and have a basic knowledge of the job expectations as described in the job description and as reviewed in the above checklist" with a place for the authentication/signature of the nurse along with the manager sign-off section. The review revealed the nurse had not authenticated or signed that she had completed the orientation check off. The review also revealed that the hospital manager of RN #1 signed off with her signature on 04/14/2010 (one day before review and during the investigation).

Interview on 04/15/2010 at 1510 with administrative nursing staff revealed RN #1 was not on orientation on 03/16/2009 when she staffed in the hospital's behavioral health DED. Interview revealed the nurse had completed orientation but her competency sheet had not been completed. Interview revealed, "Her competency sheet was found yesterday in the house supervisor's box of things to do." Interview confirmed the competency sheet should have been completed and the nurse should have signed the checklist at the end of her orientation.

A review of the hospital's behavioral health contact sheet dated 03/30/2010 at 1830 revealed a request by a government agency for the release of Patient #7's medical record. Review of the contact sheet revealed the representative called the hospital regarding a "high profile situation reference the patient and stated that the patient after discharge killed his wife and himself." An interview with the hospital's administrative staff on 04/14/2010 at 1530 revealed the patient had killed his wife and children at an unknown time after discharge. The interview revealed the hospital declared the event as a sentinel event and were investigating the visits that the patient made to the hospital's behavioral health DED.

Consequently, Patient #7 presented to the hospital's behavioral health dedicated emergency department twice, on 02/28/2010 and 03/16/2010, with complaints of wanting to hurt wife and depression. The patient was screened and assessed by the nursing staff and ED physicians at the hospital's behavioral health DED. The patient was discharged home both visits with prescriptions given by the physicians. The nursing staff and ED physicians at the hospital did not notify the identified victim of the homicidal ideations and/or police, as identified in the hospital's policy for "Duty to Protect or Warn." After the patient's discharge from the DED on 03/16/2010, the patient killed his wife, his children and himself.


NC00063504