HospitalInspections.org

Based on observation of video surveillance footage, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure an occurrence report is completed in one (1) out of one (1) incidents observed.

Findings include:

Reference: Facility policy titled: "Occurrence Reporting" states: "...To provide a process for any unusual, unexpected or potential adverse occurrence... All team members are required to complete an Occurrence Report whenever they believe that the definition of an occurrence has been met....."

1. On 11/17/2021 at 3:13 PM, a surveillance video was reviewed in the presence of Staff #1, Staff #3, and Staff #8. The video showed Emergency Department (ED) surveillance from two (2) camera viewpoints for the date of 8/26/2021 from approximately 6:30 PM to 7:10 PM. The video did not contain audio. The video identified the following:

a. Patient #2 walking out of his/her ED room on 8/26/2021 at 6:31 PM towards the nurse's station and motioning aggressively towards staff members.

b. Staff #13, a security guard, arrived to the scene at 6:33 PM, and walked with the patient back into his/her room. A second security guard, Staff #15, arrived at 6:34 PM. At 6:57 PM, a third security guard, Staff #24 arrived in the hallway outside the patient's room.

c. At 7:05 PM, all three guards and two (2) other staff members walk into the patient's room, and then they all walk back out at 7:07 PM.

2. An interview with Staff #8, a supervisor, identified that the above findings would meet the definition of an occurrence, and that an occurrence report should have been filled out. Upon request to Staff #8, the facility was unable to provide evidence of an occurrence report being completed regarding the viewed occurrence with Patient #2.

A. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that the emergency department psychiatric treatment plan is coordinated with the patient's family as per policy in one (1) out of two (2) medical records reviewed of psychiatric patients that are minors (age less than eighteen) (Medical Record #1).

Findings include:

Reference: Facility policy titled: "Emergency Psychiatric Evaluation" states: "...The evaluation process will consist of: -EPS (Emergency Psychiatric Services) team will attempt to contact the patient's family members... to gather information to coordinate treatment recommendations....."

1. Patient #1, a thirteen (13) year old, presented to the facility emergency department (ED) on 9/30/2021 with psychiatric complaints requiring evaluation. A review of the medical record for Patient #1 identified that the patient was taking the antidepressant medication, Zoloft for a history of depression. The medication, Zoloft, was discontinued after Staff #12, a physician, spoke with the patient regarding the medication and its effects on the patient. The medical record lacked evidence that the change in treatment was discussed with the patient's family.

2. An interview on 11/17/2021 at 11:45 AM with Staff #1 and Staff #2 confirmed the above findings.

B. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure the emergency department physician coordinated the patient's plan of care with the other members of the emergency department clinical providers in one (1) out of three (3) medical records reviewed of psychiatric patients in the emergency department (Medical Record #7).

Findings include:

Reference: Facility policy titled: "EMTALA [Emergency Medical Treatment and Labor Act]" states: "...The Hospital must provide an appropriate Medical Screening Examination within the capability of its emergency department ("ED")... to determine whether an Emergency Medical Condition exists... A Medical Screening Examination is an ongoing process... The patient's record shall reflect continued monitoring in accordance with the patient's needs...".

1. Patient #7 presented to the ED on 11/16/2021 at 4:44 PM with psychiatric complaints requiring evaluation. A review of the medical record for Patient #7 identified a physician note written by Staff #12 on 11/17/2021 at 10:25 AM that stated: "...RECOMMENDATIONS... Check b12 [Vitamin B 12], folate, tsh [Thyroid Stimulating Hormone], fT4 [Thyroxine], vitD [Vitamin D] if not already checked. Check/monitor EKG [Electrocordiogram], if QTc [QT Interval] >500msec, HOLD all neuroleptics, antidepressants, also recommend monitoring MG2+ [Magnesium] and keep at 2.0 and keep K+ [Potassium] at 4....." The medical record lacked orders from Staff #12 for the recommendations made, therefore ED nursing staff caring for the patient were unable to provide the treatment and monitoring as recommended.

2. An interview with Staff #9 on 11/18/2021 at 1:05 PM confirmed the above findings, and that there was lack of coordination of care with this patient between the physician and the nursing staff.