The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JACKSON HOSPITAL & CLINIC INC 1725 PINE STREET MONTGOMERY, AL 36106 March 20, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews, medical record reviews, review of Emergency Medical Treatment and Labor Act (EMTALA) policies, policies related to care of Emergency Department patients, Emergency Medical Services (EMS) / Ambulance Reports and Medical Staff Rules and Regulations, Hospital # 1 failed to:

Arrange appropriate transfers of Patient Identifier (PI) # 1 and PI # 9, patients who required further stabilization of a Psychiatric Emergency Medical Condition and inpatient psychiatric treatment.

This deficient practice affected 2 of 29 sampled patients presenting to the Emergency Department (ED), and has the potential to affect all patients with psychiatric conditions who present to the ED at Hospital # 1 and require transfer to another hospital for inpatient psychiatric treatment.

Findings include:

Refer to A2409 for findings.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, Emergency Medical Services (EMS) / Ambulance Report, Emergency Treatment and Labor Act (EMTALA) related Policies and Procedures and Medical Staff Rules and Regulations, and interviews, it was determined Jackson Hospital (Hospital # 1) failed to arrange an appropriate transfer of Patient Identifier (PI) # 1 and PI # 9, two patients determined to be a danger to self and/or others, by failing to arrange transfer after the Emergency Medical Screening was completed and the need for inpatient psychiatric treatment was identified, thereby, delaying stabilizing treatment for both PI # 1 and PI # 9.

As a result of this deficient practice, PI # 1's and PI # 9's psychiatric treatment was delayed. This deficient practice affected PI # 1 and PI # 9, two of 29 sampled patients presenting to the Emergency Department (ED), and has the potential to affect all patients with emergency psychiatric conditions who present to the ED at Hospital # 1 and require transfer to another hospital for inpatient psychiatric treatment.

There are no psychiatric services available at Hospital # 1.

Findings Include:

Policies and Procedures / Guidelines - Hospital # 1:

Nursing Service Department Guideline
Subject: Psychiatric Patient: Mental Health Plan

Effective: May 2003
Last Review Date: May 2009

Note: Psychiatric patients may be held in the Emergency Department awaiting disposition to other psychiatric services. Maintaining the dignity of the patient is a priority while maintaining a safe environment for the patient...

...1. Upon arrival to the Emergency Department
a. Mental health patients are triaged and provided with a medical
screening exam...

3. Moving patients out of the Emergency Department:

Medically stable patients in need of inpatient psychiatric services:

A. These patients need to be placed in an appropriate acute mental heath unit as soon as accepting facility is available.


EMTALA (Emergency Medical Treatment and Labor Act) Policy # 514

Original Policy: September 2008
Effective: March 19, 2013

I. Policy
All patients presenting for treatment will receive, after the initial triage, a Medical Screening Examination (MSE) by Qualified Medical Personnel to determine whether an Emergency Medical Condition (EMC) exists...

4. In the event the MSE does reveal an Emergency Medical Condition;
- Appropriate treatment or transfer shall be rendered immediately...

II. Purpose

All patients presenting to Jackson Hospital with a potential EMC will be evaluated through a triage system and receive an appropriate MSE. If a patient is determined to have an EMC, we will stabilize and/or transfer the patient in accordance with the Emergency Medical Treatment and Labor Act...

III. Emergency Medical Condition (EMC):

An EMC is a medical condition manifesting itself by acute, severe symptoms (including pain, psychiatric disturbances, and/or symptoms or substance abuse) that, without immediate medical attention, could result in
- Placing the health of the patient...in serious jeopardy...

In an EMC exists:
- Jackson Hospital will provide appropriate treatment to stabilize the EMC.
- If the needed treatment cannot be provided at Jackson Hospital, with the patient's consent, the patient may be transferred to another facility after stabilization if:
- the type of care required by the patient is unavailable.
- We (Jackson Hospital) are on diversion...

IV. Procedures:

Patient Transfers:

Transfer of an Unstable Patient to Another Facility after a MSE:

If the patient has an EMC that has not been stabilized, Jackson Hospital will not transfer the patient unless:
...A physician completes an Authorization and Consent for Patient Transfer Form as a verification that the benefit of the transfer exceeds the risk(s).

- At a minimum, the certification will include a summary of the risks and benefits of the transfer, documentation of the EMC, the lack of service availability, and/or other pertinent facts.

- The name of the receiving physician and facility, the facts requiring the patient's transfer, and the date and time of the contact must also be included...

Prior to any transfer to another facility, Jackson Hospital will:

...Contact, confirm, and document that the receiving physician agrees to accept transfer of the patient and report given to the receiving facility using
Authorization and Consent for Patient Transfer Form.

- Forward copies of all copies of all medical records...and physician's certification to the receiving facility...


Medical Staff Rules and Regulations:

October 13, 2014

Emergency Medical Services:

1. Screening, Treatment and Transfer

..."The condition of all ill or injured persons presenting to the Emergency Department of the hospital shall be determined and the patient either treated or referred to an appropriate facility as indicated. Appropriate transfer agreements must be confirmed with the receiving facility and practitioner prior to the transfer."


1). PI # 1 - Jackson Hospital (Hospital # 1):

PI # 1 arrived at Jackson Hospital's Emergency Department (ED) via ambulance on 3/10/15 at 00:21.

Triage 3/10/15 - 00:32: EMS (Emergency Medical Services/Ambulance staff reports PI # 1 lives in senior apartments. Apartment staff told EMS PI # 1 had been pulling the call light and exhibiting "erratic" behavior all day. EMS states PI # 's daughter is attempting to have the patient committed. History of Schizophrenia and Hypertension. Acuity: 2 (Emergent).

The EMS report, documented by the triage RN (Registered Nurse), as the triage assessment is a reiteration of the EMS report. The RN's evaluation of PI # 1's psychiatric symptoms are not documented.

Triage Vital Signs: Blood Pressure: 143/86, Pulse: 71, Temperature: 97.8, Respirations: 20.


ED Physician Documentation: 3/10/15 at 00:40:
Arrived by ambulance.
Informant: paramedics.
Complaint: Agitated, hallucinating.
Onset: 3 days ago and continues in ED.
Severity: moderate.
Associated Symptoms: frustrated, agitated, hostile, hallucinating.

Review of Systems: Memory loss, anxiety.

History: Cardiac Disease, Congestive Heart Failure.

Psychiatric Problems: Schizophrenia.

Physical Examination:
Constitution: No acute distress. Anxious.
ENT (Ears, Nose, Throat): Normal inspection.
Eyes: PERRL (Pupils Equal, Round, Reactive to Light), Extraoccular movement intact.
Neurological: Disoriented to time and situation.
Cranial Nerves: Normal (2-10). Normal sensory response.
Psychiatric: Hostile.
Neck, Back, Respiratory, Cardiovascular, Abdomen, Skin and Extremities: Normal.
EKG (Electrocardiogram): Normal sinus rhythm.
Chest x-ray: No infiltrates, normal heart size, normal mediastinum.
Complete Blood Count with differential, Comprehensive Metabolic Panel... within normal limits. Ethanol level: 1 mg/dL (deciliter)

Progress: 03:10: Improved. Cleared medically for psychiatric evaluation.

Clinical Impression: Psychosis (severe mental disorder characterized by loss of contact with reality), acute exacerbation.

Disposition: Transfer.

Condition: Improved. Stable.

"Care transferred to Dr. (name of psychiatrist)."

This is a certified medical emergency.

A review of the Patient Hold Form dated 3/10/15 (time not documented) reveals PI # 1 was examined and determined to have signs and symptoms of mental illness, that he/she is likely to be of immediate danger to self or others and, therefore, pursuant to 22-8-1 of the Code of Alabama 1975, the patient is being held without his/her consent for further evaluation and treatment... The basis of the decision to hold the patient for evaluation and possible commitment is based upon: statements and actions of the patient. The form, signed by the ED physician who performed PI # 1's medical screening examination and another ED physician, fails to document the time the hold was initiated.

A review of the Medication Administration Record dated 3/10/15 revealed PI # 1 received Ativan 2 mg. (milligrams) IV (intravenous ) stat (immediately) and Geodon 10 mg. IM (intramuscular) stat at 01:08. There is no documentation of the patient's behavior to explain the need for the medication.


Daily Focus Nursing Assessment:

3/10/15 - 01:30: Alert, oriented x 4, cooperative, speech clear. Agitated and restless. Family at bedside. (Although family present, there is no documentation of attempt by RN to obtain information about the patient's psychiatric symptoms and behavior prior to arrival in the Emergency Department).

3/10/15 - 07:50: Patient is talking to people in the room that are not there... Speech garbled.

A review of the Medication Administration Record dated 3/10/15 reveals the patient received Ativan 2 mg. stat at 05:10. There is no documentation in the Daily Focus Nursing Assessment about the patient's psychiatric symptoms that warranted administration of Ativan.


Psychiatric Evaluation by Mental Health Therapist: 3/10/15 - 08:45:

Patient presents to Jackson ED with psychosis and history of Dementia. Patient is difficult to interview because PI # 1 is actively psychotic. Patient's daughter reports PI # 1 was in another hospital for over one month and discharged on [DATE]. Daughter reports patient was "not ready" and has been "screaming, yelling, aggressive." Patient's thought processes are disorganized. PI # 1 reports seeing babies in the sky and stated, "I have two babies to give birth to. That's why I'm here." Patient's speech is slurred. Disoriented to person, place, time and situation. Patient is talking and conversing without anyone present and can be loud at times. Patient presents delusional and discussed being pregnant and on honeymoon in France. Patient has no insight into actions.

Consulted with (name of psychiatrist in Community Mental Health System) who has a history of treating PI # 1. States PI # 1 has a history of Dementia and is "continually psychotic." This psychiatrist recommends Emergency Hold and admission to inpatient geriatric psychiatric unit.


Daily Focus Nursing Assessment (PI # 1 - Hospital # 1):

3/10/15 - 11:10: Patient is agitated and screaming out into the hallway at staff. Geodon IM given.

A review of the Resource Management Note dated 3/10/15 at 13:34 revealed: Pt. was evaluated by the (Named) Area Mental Health Authority and it was determined that patient needs inpatient psychiatric treatment. Information sent to Hospital # 3. Patient has been there previously. Awaiting determination.

A review of the Resource Management Note dated 3/10/15 at 13:37
revealed: Spoke with (name of psychiatrist) at Hospital # 3. Psychiatrist stated that he would not take patient unless patient is petitioned by probate court for involuntary commitment.

A review of the Resource Management Note dated 3/10/15 at 13:42
revealed: Staff from Probate Court called and stated family is at court to file petition for involuntary commitment...Case Manager explained patient psychotic, hallucinating and saying she is, "Pregnant and needs to get the baby out of her."

A review of the Resource Management Note dated 3/10/15 at 14:52 revealed: Received permission from probate court for involuntary commitment. To be transported to Hospital # 2.

3/10/15 - 15:29: Petition for Involuntary Commitment of PI # 1 by the Probate Court reveals PI # 1 is currently located at Hospital # 1's Emergency Department and is to be taken to Hospital # 2's ER/Psychiatric Hospital.

Daily Focus Nursing Assessments:

3/10/15 - 16:05: Sheriff here to transport patient per court order from probate judge. (There is no documentation about the patient's psychiatric condition / symptoms).

3/10/15 - 16:25: "Patient not able to get into sheriff van for transport." (There is no documented explanation about the patient's inability to get into the van). "Ambulance called for transport to Hospital # 2 as court order states."

The Consent and Transfer Form (Hospital # 1) dated 3/10/15 reveals Hospital # 2 has agreed to accept transfer of PI # 1. The name of the person accepting the transfer is documented as (name of psychiatrist). Time contacted and time accepted: 09:30 AM.

A review of the Ambulance Report dated 3/10/15 at 16:25 reveals, "Arrived on scene...Pt. (patient) was verbally combative, confused, hallucinating. Transferred pt...to stretcher...Chief complaint was psych (psychiatric) evaluation..." Transported to Hospital # 2's ED at 16:39.

Medical Record Review of PI # 1 at Hospital # 2 (Receiving Hospital):

Triage: 3/10/15 at 17:00.
Medical screening 19:15: Suffering from delusions and schizophrenia, but denies current symptoms.

The ED nursing documentation revealed the patient was agitated and exhibited delusions and hallucinations on 3/10/15 at 19:57. At 22:02 on 3/10/15 the patient was threatening to physically assault staff. The patient was medicated, but the name of the medication was not documented in the nursing note.

On 3/11/15 at 00:15 the patient contained to yell, bang on the window and ask about items not visible to staff. At 04:55 on 3/11/15 the patient continued to scream. The patient was yelling at 10:58 on 3/11/15 and requested medication. Medication was given, but it was not documented in the nursing note.

The patient was transferred to Hospital # 2's Psychiatric Unit on 3/11/15 at 17:51, more than 24 hours after arrival in the ED at Hospital # 2.


Interviews - Hospital # 1:

During an interview on 3/18/15 at 14:27, the Emergency Department (ED) Case Manager (CM) / Resource Management, Employee Identifier (EI ) # 1, stated if a psychiatric patient is committed by the court, placement is pre-determined by the Probate Judge and the patient is medically cleared, the patient is discharged from the ED to the custody of the sheriff for transport. When a patient is court ordered to treatment at Hospital # 2, Hospital # 1 does not complete a consent for transfer form.

Regarding PI # 1, the ED CM said prior to the court commitment of PI # 1, she tried to find an appropriate hospital to accept PI # 1. Mental Health staff (non hospital employees) come to the ED to evaluate psychiatric patients at the request of Jackson Hospital.

During an interview on 3/18/15 at 16:55, EI # 1, ED Case Manager (CM) stated when PI # 1 presented to the ED, the patient did not have a court petition. According to the CM, she spoke with (name of psychiatrist) at Hospital # 3, but he would not accept PI # 1 without a court petition. While the CM continued to find another hospital to accept the patient, she was informed by Probate Court that a petition had been filed for PI # 1. The CM received a call from the Sheriff's office advising they were coming to transport the patient to Hospital # 2. The CM stated Hospital # 1 does not consider a patient court ordered to treatment a transfer because the court makes arrangements to include ascertaining bed availability at the receiving facility, not the hospital. Hospital # 1 considers the patient as a discharge and they do not talk to the receiving physician or staff at the receiving facility. According to the CM, PI # 1's consent for transfer form was completed in error. PI # 1's disposition was considered a discharge of a probate court ordered/committed patient who was medically cleared. The CM said PI # 1 was not a transfer. Review of PI#1 ' s Consent to Transfer Form dated 3/10/2015 revealed that PI#1 was transferred and not discharged .

During an interview on 3/18/15 at 16:45, the ED Physician (EI # 2) who signed the Consent and Transfer Form for PI # 1 on 3/10/15, confirmed the accepting psychiatrist as the receiving physician at Hospital # 2. Regarding patients with court orders for treatment the physician said, "We (Jackson Hospital) don't know where the patient is going. We haven't made the arrangements."

According to the facility's Medical Staff Rules and Regulations, "The condition of all injured persons presenting to the Emergency Department of the hospital shall be determined and the patient ...referred to an appropriate facility as indicated. Appropriate transfer agreements must be confirmed with the receiving facility and practitioner prior to transfer."

During an interview on 3/19/15 at 10:00, EI # 1, ED Case Manager, said if a patient has a court petition, the judge determines where the patient will be sent for treatment. "We (Jackson Hospital) don't have an accepting MD. The patient is discharged from the ED. We are following the judge's order."

During an interview on 3/10/15 at 11:00, the ED Charge Nurse (EI # 6) stated PI # 1 was court ordered to treatment at Hospital # 2. According to the charge nurse, the sheriffs who came to the ED to transport PI # 1, said the patient refused to get in their van and insisted that EI # 6 call an ambulance to transport the patient.

The Charge Nurse stated, "I don't call the hospital because (name of case manager) takes care of that." The nurse said the RN assigned to PI # 1 "attempted" to call report about the patient to the charge nurse at Hospital # 2. EI # 1 said she did not know the outcome of that call. However, the charge nurse said she received a call from from the charge nurse at Hospital # 2 and gave report about PI # 1. This communication is not documented in PI # 1's medical record.

During an interview on 3/19/15 at 17:00, the ED Physician, EI # 3, responsible for PI # 1's medical screening examination on 3/10/15, stated because PI # 1 was admitted after 17:00 the mental health evaluation was not done until the following morning. When asked if he spoke with the psychiatrist documented on the transfer consent form as the receiving MD at Hospital # 2 he said, "Probably. I usually do."

During an interview on 3/20/15 at 10:25, the Assistant ED Manager (EI # 4) and the ED Manager (EI # 5) verified that no consent transfer form is required when a patient is court ordered to treatment at another hospital. The patient is discharged to the custody of the sheriff responsible for transporting the patient. The use of the Consent and Transfer Form to transfer of PI # 1 to Hospital # 2 on 3/10 15 was a "mistake." According to the managers, there is no contact by Jackson Hospital with the MD at the receiving hospital because probate court arranges the transfer.

Summary, PI # 1 arrived in the ED at Hospital # 1 on 3/10/15 at 00:32. Although the ED physician determined the patient was "cleared medically for psychiatric referral" at 03:10, no arrangements were documented and/or made to transfer PI # 1 to a psychiatric facility. Although the ED physician responsible for PI # 1's medical screening documented the patient's care was transferred to (name of psychiatrist), no physician to physician communication is documented in the medical record as required according to Hospital # 1's Medical Staff Rules and Regulations. The mental health evaluation was documented at 08:45, more than eight hours after the medical screening evaluation was completed and the need for psychiatric treatment was identified. Over sixteen hours after arrival at Hospital # 1, PI # 1 was transported to Hospital # 2, representing an inappropriate transfer and a significant delay prior to the transfer of this patient identified as high risk by Hospital # 1's ED staff.


2. PI # 9 - Jackson Hospital (Hospital # 1):

PI # 9 arrived at Hospital # 1's Emergency Department (ED) via private vehicle on 3/15/2015 at 18:45. According to the Triage Report at 18:57, PI # 9 complained of visual hallucinations for one week.

Vital Signs: Blood Pressure 169/80, Pulse 100, Respirations: 20.

ED Nursing Progress Notes:

3/15/2015 at 21:11: Family states PI # 9 is hearing voices. Violent commands for two days. Patient also verbalizes violent command hallucinations.

3/15/2015 at 22:00: "Pt. (patient), PI # 9, medicated and placed on hold...Pt. will be held and seen in am."

3/15/2015 at 22:44: Pt. given Haldol and Cogentin orally.

3/16/2015 at 05:30: "...Awaiting psych."

3/16/2015 at 09:00: "... (name of local Mental Health staff) in to see."

3/16/15 at 13:16: "... Pt. (PI # 9) aware of pending transport to (Mental Health facility)."

3/16/15 at 13:45: Disposition: Transfer. "Escorted to (Mental Health Facility) per...Sheriff."


Medical Screening Examination: 3/15/2015 at 19:07

Patient (PI # 9) reports hallucinating for hours and continues in the Emergency Department (ED). Severity: Severe. Associated Symptoms: Depressed.

Psychiatric Problems: Depression, Bipolar Disorder and Schizophrenia.

Plan: Psychosis, acute exacerbation.

Patient is harm to others.

Disposition: Transfer.

Condition: Improved. Stable. This is a certified medical emergency.

Resource Management Note for PI # 9 dated 3/16/1015 at 09:42:

Pt. (PI #9) was evaluated by (Named Area Mental Health Authority) and it was determined inpatient psychiatric treatment needed, but patient unwilling to go for treatment. Mental Health Authority to petition probate court for involuntary commitment.

Petition for Involuntary Commitment :

PI # 9 has a history of psychiatric treatment with Named Mental Health Authority ... and has a previous diagnosis of Schizophrenic Disorder, Schizo-Affective Disorder, Schizo Affective Type. PI # 9 is currently at Jackson Hospital ER (emergency room ) and is refusing inpatient treatment...has delusional thinking regarding high school boys who are trying to fight (him/her). Has had very aggressive behavior at home, is preoccupied, disoriented to time and day and is seeing faces of people who are not there. The petitioner believes PI # 9 is a threat to self and others and is in need of treatment for stabilization. Without treatment PI # 9's condition will continue to worsen.

In summary, PI # 9 received a Medical Screening Examination on 3/13/15 at 19:07 at Jackson Hospital's ED. The Physician determined the patient was psychotic and was a danger to others. There are no psychiatric services at Jackson Hospital. PI # 9 was evaluated by an outside psychiatric provider (Named Medial Health Authority - MAMHA) on 3/16/15 at 9:26 AM, fourteen hours and 26 minutes after the ED Physician determined the patient was a harm to others and ordered a psychiatric evaluation. Transfer of PI # 9 from the ED to (Mental Health facility) occurred on 3/16/15 at 13:45, 18 hours and 26 minutes after the Medical Screening Examination (MSE). This represents an inappropriate transfer and a significant delay prior to the transfer of PI # 9, a patient identified as a risk to harm others by Hospital # 1's ED staff.

The hospital failed to ensure their procedure titled, "Transfer of an Unstable Patient to Another Facility after a MSE (Medical Screening Examination) was followed for PI # 9 on 3/15/2015 as evidenced by failing to:
1). Ensure the physician completed an Authorization and Consent for Patient Transfer Form (physician written certification for transfer).
2). Contact, confirm and document the receiving physician agreed to accept transfer of the patient (PI # 9); and
3). A report was given to the receiving hospital using the Authorization and Consent for Patient Transfer form.