HospitalInspections.org

A. Based on review of Hospital Guidelines for Patient Taxi Vouchers, clinical records, and staff interview, it was determined that, for 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to ensure patient discharge needs were met.

Findings include:

1. The Hospital Guidelines for Patient Taxi Vouchers was reviewed on 05/16/11 at approximately 1:20 PM. These guidelines required "...A staff member must make an attempt to contact an emergency contact..."

2. The clinical record of Pt #1 was reviewed on 05/16/11 at approximately 9:30 AM. Pt #1 was a 35 year old male that presented to the Emergency Department by ambulance on 1/31/11 at approximately 6:34 PM with a diagnosis of Opioid Overdose. The clinical record contained documentation of Crisis Intervention dated 02/01/11 done via telephone with time documented from 12:30 AM - 1:45 AM with the Centegra Health System Counselor. The documentation included a discharge plan that required "...Spoke to E #1 who agrees to pt discharge. States pt had never made threat of suicide or indication that he doesn't want to live. Spoke to E #1 about living situation and concern that if pt returns home, issues would arise. Explained reasons pt should go to a family member's home for night. E #1 agrees. Provided discharge instructions and referral information to ER nurse." The clinical record contained physician discharge orders dated 02/01/11 at 12:53 AM and documentation of nurse's discharge instructions given to and signed by patient at 1:19 AM. The clinical record lacked documentation of any attempt by staff to contact Pt #1's emergency contacts at time of discharge to arrange transportation home. The clinical record contained a copy of the Taxi Charge Ticket dated 02/01/11 that showed a pick-up time of 7:05 AM from the Hospital (5 hours 46 minutes after Pt #1 was discharged) and drop-off time of 7:30 AM (at Pt. #1's home address, instead of a family member's home, as instructed in discharge plan).

3. During interview with the Director of Emergency Trauma (E #2) and the nurse caring for the patient (E #3) on 05/16/11 at approximately 2:50 PM, E #2 and E #3 stated that when a patient is discharged in the middle of the night and they do not want to wake anyone for a ride, patients are allowed to sleep in the lobby until morning or are provided with a Taxi Cab voucher.

4. Findings were confirmed with E #2 during interview on 05/16/11 at approximately 2:00 PM.

A. Based on review of Hospital policy, contractual service agreement, clinical records, and staff interview, it was determined that, for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure the off campus Crisis Team conducted psychiatric assessments onsite.

Findings include:

1. On 5/16/11 at 9:00 AM, the policy titled, "Psychiatric Patients, Admission, and Evaluation in the Emergency Department" was reviewed. The policy required, "...The emergency department physician or McHenry Crisis team shall conduct a complete assessment..."

2. On 5/16/11 at 9:15 AM. the contractual agreement with Centegra Health System (McHenry County Crisis Services) for crisis intervention was reviewed. The agreement included, "II. Crisis Team Clinical Services: A. Emergency Department: Crisis Team will provide staff members who have training in the evaluation and assessment of psychiatric patients to evaluate patients who present to the Emergency Department (ED)... Upon arrival at [the Hospital], the Crisis Team staff... will conduct an assessment of the patient..." The agreement did not provide a stipulation for an off campus phone assessment.

3. The clinical record of Pt. #1 was reviewed on 5/16/11 at approximately 9:30 AM. Pt. #1 was a 35 year old male, presenting to the ED on 1/31/11, with a diagnosis of Opioid Overdose. The Emergency Medical System Ambulance report dated 1/31/11, included, "Patient wanted to hurt himself." A physician's order dated 1/31/11 at 7:13 PM, included, "Behavioral Health Screen". A nursing note on 1/31/11 at 11:28 PM, included, "Crisis contacted for evaluation, medically cleared." A nursing note on 2/1/11 at 1:05 AM, included, "...Crisis did evaluation via phone. Patient cleared to go home with family..."

4. On 5/16/11 at 2:55 PM, an interview was conducted with the Registered Nurse (E #3) who cared for Pt. #1 on the 1/31/11 (night shift). E #3 stated that hazardous driving conditions due to snow fall may have been a factor in the Crisis Team conducting a psychiatric assessment over the phone, instead of coming to the Hospital. E #3 stated that this event was the only occasion that he could recall when the Crisis team conducted a phone assessment instead of face to face.

5. On 5/16/11 at 3:00 PM, this finding was confirmed by the Director of Quality and Public Safety, during an interview.