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.

MOBILE INFIRMARY MEDICAL CENTER 5 MOBILE INFIRMARY CIRCLE MOBILE, AL 36652 April 21, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Medical Staff Rules and Regulations, facility policies, ambulance patient care report, contracts, physician on call schedule, hospital census reports, medical records and interviews, it was determined the facility failed to ensure:

1. that a medical screening examination was completed for Patient Identifier (PI) # 1, a patient who arrived at the facility's emergency department (ED) by ambulance on 2/22/16 with chief complaint of combative behavior and dementia.

2. that the on call psychiatrist presented to the emergency department when requested for PI # 2, a patient who (MDS) dated [DATE] with diagnosis of Suicidal Ideation (SI) and a history of Bipolar and Schizophrenia.

3. that stabilizing treatment was provided for PI # 2, a patient who (MDS) dated [DATE] with diagnosis of Suicidal Ideation (SI) with a history of Bipolar and Schizophrenia, which the facility had the capacity to treat.

These deficient practices affected 2 of 27 medical records reviewed and has the potential to negatively affect all patients who present to this facility's ED with an emergency medical condition.


Findings include:

Refer to findings at A2404, A2406 and A2407.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Bylaws, Policies, and Rules and Regulations, Facility Policies, Services Agreement, Employment Agreement (contracts), physician on call schedule and medical records, it was determined the facility failed to ensure the on call psychiatrist presented to the emergency department (ED) to provide psychiatric consultation for Patient Identifier (PI) # 2, a patient who (MDS) dated [DATE] with diagnosis of Suicidal Ideation (SI) with a history of Bipolar and Schizophrenia.

This affected 1 of 27 medical records reviewed and had the potential to negatively affect all patients who present to this facility's ED with psychiatric complaints.

Findings include:

Review of the Medical Staff Bylaws
Revised and Adopted by the Medical Staff: June 17, 2013
Approved by the Board: September 16, 2013

Article 2

Categories of the Medical Staff

2. A Active Staff:

... 2.A.3. Responsibilities:

(a) Active staff members must assume all the responsibilities of membership on the Active Staff, including...

(2) providing specialty coverage for the Emergency Department;

(3) providing care for unassigned patients...

(6) accepting consultations when requested....

Review of the Medical Staff Rules and Regulations:
Adopted by: The Medical Executive Committee, August 9, 2013
Approved by: The Board, September 16, 2013

Article X
Emergency Services

10.3. On-Call Responsibilities:

It is the responsibility of the scheduled on-call physician to respond to calls from the Emergency Department in accordance with Medical Center rules and regulations...

Review of facility polices:

Policy: Medical Staff Coverage Emergency Department
Approval Date: 7/2/2013

Purpose: To establish a process for Emergency Department medical staff coverage.

Policy:

A. Patients admitted to the Emergency Department should be attended by a member of the Medical Staff of Team Health or the Medical Staff of Mobile Infirmary...

C. In the event a patient presents for treatment who has no attending physician, such patients should be assigned in accordance with the Unattached On-Call Physician (EMTALA) Schedule, after an evaluation by the Emergency Department physician to determine the medical specialist required for the patient's complaint and follow-up. (See Unattached On-Call Physician (EMTALA) Schedule Policy in the Administrative Manual.)...

Policy: Unattached On-call Physician (EMTALA) Schedule
Approval Date: 5/23/2013

Policy:

Participation in the Unattached On-Call Physician (EMTALA) Schedule is a requirement of membership in the Mobile Infirmary Medical Center's Medical Staff (Attending, and Courtesy members). The Unattached On-Call Physician (EMTALA) schedule is developed quarterly and distributed to the members of the Medical Staff and the Emergency Department.

An on-call physician who fails to respond or does not appropriately respond in 30-45 minutes may be subject to summary restriction or suspension of their privileges...

Review of the Services Agreement dated 4/14/14 between Horizon Mental Health Management and Mobile Infirmary Medical Center revealed:

"... Agreement: Pursuant and subject to the terms and conditions hereinafter set forth, Hospital hereby retains the services of Horizon to assist in the operation of a geropsychiatric inpatient programs and an adult psychiatric inpatient program by Hospital and Horizon agrees to provide the services necessary to assist in the provision of such psychiatric services by Hospital for the consideration specified herein (the "Program")...

... Covenants of Hospital

Hospital covenants and agrees that, at the Hospital's expense, Hospital shall:

... (m) Agree that licensed psychiatrists who are members of Hospital's medical staff may admit and practice in the Program, and that Hospital will maintain and implement a medical staff review procedure to address attending physicians' performance issues in accordance with Hospital medical staff bylaws...

... Covenants of Horizon

Horizon covenants and agrees that it shall:

... (c) Provide the Program staff as needed for the Program, including but not limited to, providing the following services... medical-administrative direction... The Horizon Program staff shall consist of the following personnel:

... Medical Director(s) Part-time Independent Contractor
Psychiatrist(s) Part-time Independent Contractor

Horizon's Medical Director responsibilities are limited solely to the provision of administrative services and not the provision of professional medical services, attending or coverage services in the absence of Program psychiatrists.

(d) With Hospital's prior approval, provide the physician recourses necessary to operate the Program in accordance with all local, state and federal governing regulatory and licensure requirements as well as any Hospital-specific departmental rules and bylaws. Such physician resources shall include psychiatrists necessary to ensure admitting, discharge, daily rounds and after hours and weekend coverage are available to ensure full utilization of the Program...

(l) Provide psychiatric consults on the medical/surgical units of Hospital, and when available the emergency department. Such consults shall be performed by Horizon's Medical Director or other Horizon Program Staff member that is a qualified mental health professional...

V. Operation of the Program

It is agreed and understood that:

(a) The Program is a service provided by Hospital to Hospital's patients and ultimate control and supervision over the Program and its operation shall reside in Hospital. The Program shall be subject to the same monitoring and oversight by Hospital as is applicable to any other department of the Hospital...

(c) The medical staff committees of Hospital, such as quality assurance, utilization review and coordination and integration of services, shall be responsible for the medical services provided in the Program.

(d) The Medical Director of the Program shall report to the Chief Medical Officer (or similar official) of Hospital in the same manner as any other medical director of a department of Hospital and shall be subject to the same type of supervision and accountability as any other department medical director...

First Amendment to Agreement between Horizon Mental Health Management and Mobile Infirmary Association dated 6/1/15 revealed the following:

5. As of the Effective Date, Section VI, Horizon Fees, paragraph (c) Pass-Through Expenses, is deleted in its entirety and replaced with the following:

(c) Pass-Through Expenses... Hospital shall also pay to Horizon any reasonable costs related to Horizon's use of External Physician Coverage such as locum tenens, mid-level/physician extenders (e.g., Nurse Practitioners and Physician Assistants), or any other External Physician Coverage required to operate the Program as agreed to in advance by the parties...

Hospital shall pay to Horizon each month an amount to the salary... and benefits... for physician performing psychiatric consults at the request of Hospital...

Review of the Employment Agreement dated 9/21/15 between Horizon Mental Health Management and Employee Identifier (EI) # 3, Psychiatrist revealed the following:

... Agreement

... 2. Representations and Warranties. Physician represents and warrants as of the Effective Date and throughout the Term... that:

(c) Physician is a member of the active medical staff of the Hospital, in good standing with all clinical privileges for which Physician qualifies...

3. Physician's Duties and Responsibilities.

(a) In addition to direct patient care responsibility, Physician shall perform the services and duties listed on Exhibit A... Pertaining to matters of medical responsibility and oversight, the Physician shall report to the Hospital Chief of Medical Staff. In addition, Physician agrees to comply with the policies, rules and regulations of the Hospital, Medical Staff and the Unit...

Exhibit A Physician's Duties

During the Term , Physician shall perform such duties and services as assigned by Horizon, such duties shall include, but not be limited to the following...

10. Coverage - Physician shall be responsible for admissions, discharges, patient care including rounds, consultation liaison, and other psychiatric duties and responsibilities including Medical Director, and on-call beginning Monday at 12:00 am through Friday, 11:59 pm...

First Amendment to Agreement between Horizon Mental Health Management and EI # 3 dated 9/21/15 revealed the following:

... Agreement

... 3 As of the Effective Date, Section 6 Compensation, Benefits, Billing and Collection, paragraph (a) Annual Base Compensation is amended to add the following subparagraph (a)(i):

(a)(i) In addition to the Annual Base Compensation, Horizon shall pay physician a fee of... per day, Monday through Friday, to be on-call to perform consults as requested by the Hospital...

Review of the November 2015 physician on call schedule revealed Employee Identifier (EI) # 3, Psychiatrist was on call from 11/26/15 through 11/30/15.

Review of the medical record for PI # 2:

PI # 2 presented to the emergency department (ED) on 11/25/15 at 5:33 PM via ambulance for psychiatric evaluation.

Review of the 11/25/15 at 5:55 PM ED Notes revealed the Registered Nurse (RN) documented the patient was brought to the ED via EMS (Emergency Medical Services) with diagnosis of Suicidal Ideation (SI) with a history of Bipolar and Schizophrenia, had been drinking for 4 days and had not taken (his/her) medications for the entire time.

Review of the RN Note dated 11/25/15 at 6:36 PM revealed the patient presented to the ED via ambulance with complaints of SI without a plan, Homicidal Ideation (HI) toward his/her father. PI # 2 denied visual hallucinations (VH), but was positive for audio hallucinations (AH), stating the "voices are telling me to kill myself". The patient had a history of Schizoaffective Disorder and had not taken psychiatric medications for 4 days while drinking. The patient was vomiting in the ED at the time. PI # 2 requested to be hospitalized at Hospital # 3. PI # 2's case was discussed with the physician.

Review of the Medical Screening Examination for PI # 2 dated 11/25/15 at 8:39 PM by the ED physician revealed:

Review of Systems: Psychiatric/Behavioral: Positive for suicidal ideas, dysphoric mood and agitations. All other systems reviewed and are negative. Patient History: Medical History: ... past medical history of Depression; Bipolar 1 Disorder, depressed; Morbid Obesity, Marijuana abuse, Suicidal ideation; and Homicidal ideation... Social History: ... reports (he/she) drinks alcohol... uses illicit drugs (Marijuana)...

Physical Exam: ... Constitutional: .... oriented to person, place and time... appears well-developed and well-nourished... Psychiatric: Judgment and thought content normal. Flat affect, disheveled...

Review of the lab results for Urine drug screen revealed PI # 2 was positive for cannabinoid (normal for this facility - negative) and urine Alcohol level was 191 {normal for this facility is less than 10 mg/dL (milligrams/deciliter)}. All other components were within normal limits.

Review of the lab results for CBC (complete blood count) revealed the patient's Hemoglobin was 12.9 (Normal for this facility: 14 to 18 gm/dL - grams/deciliter), Lymphocytes - automated 44 (normal for this facility 20 - 40 %). All other components were within normal limits.

(Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs. Lymphocytes are responsible for immune responses. www.medicinenet.com).

Comprehensive Metabolic Panel (CMP) revealed the patient's Glucose 102, {normal for this facility is 70-99 mg/dl (milligrams/deciliter)} and Albumin 3.4 (normal for this facility 3.5-5.0 gm/dL). All other components were within normal limits.

(CMP is a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function. Albumin is a protein in the blood, which helps keep blood from leaking out of the blood vessels and helps carry some medicines and other substances through the blood and is important for tissue growth and healing. www.webmd.com)

Review of the RN documentation on 11/25/15 revealed the following:

9:31 PM - the (patient's) chart was sent to Hospital # 3 and was awaiting call from them.

10:46 PM - Hospital # 3 called and was unable to accommodate the patient at that time and stated the referral may be revisited in the morning. The patient was also denied admission into this facility's psychiatric unit related to alcohol intoxication per Employee Identifier (EI) # 4, Psychiatrist. The patient's case was discussed with the ED physician at that time.

11:48 PM - the patient was resting comfortably at that time and a sitter was present at bedside.

Review of the RN documentation on 11/26/15 revealed at 1:16 AM and 3:05 AM the patient was resting comfortably and a sitter was present at the patient's bedside.

Review of the RN documentation on 11/26/15 revealed the following:

3:25 AM - the patient stated he/she needs help; explained to the patient that neither the physician here or at Hospital # 3 would be able to accommodate him/her this evening; the patient was requesting to go home and the case was discussed with the physician at that time.

4:00 AM - the patient was resting with no distress.

4:18 AM - Due to the patient being denied admittance to Hospital # 3 and MI (Mobile Infirmary) Psych unit, ED physician has requested that psych intake contact EI # 3, Psychiatrist on call to request a psychiatrist consult in the ED.

Review of the Physician Consult Order dated 11/26/15 at 4:22 AM revealed orders for a one time physician consult for EI # 3, Psychiatrist due to the patient being denied admittance to two psych units, but the patient still claimed to be suicidal. The order priority was STAT (A common medical abbreviation for urgent or rush) and was referred to EI # 3.

5:49 AM - the patient was resting with no distress.

9:06 AM - the patient was agitated during interview this morning. Maintains that he/she is suicidal and wants to hurt father. states... is on outpatient commitment for multiple things and is seeing (Mental Health) for therapy and out patient services. States last appointment is for December 1st. The patient's mother stated she filed probate in August. Called (Access center for Hospital # 3) and discussed the patient and will fax the patient's chart again. The patient's alcohol level is zero this morning.

9:34 AM - Called 5 SE (Southeast - Adult Psychiatric Unit), 5W (West - Geripsychiatric unit) and EI # 3's number to discuss ED consult placed for the patient to help with disposition. The RN was unable to get in touch with EI # 3 at that time. PI # 2 was listed on EI # 3's rounds list. Will continue to try to contact (EI # 3).

10:04 AM - Spoke with EI # 3 and updated him on this patient. EI # 3 does not make rounds in the ER (emergency room ). EI # 3 stated that if patient violated out patient commitment that Hospital # 3 is supposed to take the patient. Discussed with (named person) at (Access center for Hospital # 3). (Named person) to discuss with (named psychiatrist at Hospital # 3). Awaiting return call.

10:36 AM - Patient medically stable to transfer per ED physician. Patient accepted at Hospital # 3 per psychiatrist for Hospital # 3.

The patient was transferred to Hospital # 3 on 11/26/15 at 11:30 AM.

Review of the Discharge Summary from Hospital # 3 for PI # 2 revealed the patient was voluntarily admitted to the facility on [DATE] with Schizoaffective disorder, Alcohol use disorder, Cannabis use disorder, Impulse control disorder, family relation problems and obesity. Reason for admission revealed the patient was under an outpatient commitment with the Bridge Team (outpatient therapy). The patient presented to the hospital from MIMC (Mobile Infirmary Medical Center) with suicidal ideation with no plan.

Hospital Course included: "... Axis I: 1. Schizoaffective disorder, 2. Alcohol use disorder, 3. Cannabis use disorder, 4. Impulse control disorder, 5. family relation problems 6. obesity. The patient was given this diagnosis because of (his/her) previous multiple presentations to psychiatric hospital as well as (his/her) presentation on recent admission where he/she admitted having spent $200.00 of father's money for drinking alcohol and said he/she wanted to get straight. Initially PI # 2 presented with SI (suicidal ideation) as well as HI (Homicidal ideation) towards father. We started PI # 2 on previous medications Trileptal 300 mg (milligrams) twice a day (bid) and Geodon 80 mg bid, the patient continued to have passive death wishes, denied active SI/HI. The patient had an outburst during a telephone call with the parents and phone restrictions were ordered. Two days later phone restrictions were lifted and the patient did great on that. On admission the patient endorsed AH (auditory hallucinations), which later resolved. The patient's mood slowly improved over the hospital stay. Upon discharge, the patient denied AH/VH or other psychotic symptoms like paranoia. The patient denied SI/HI and was deemed safe for discharge..."

Interviews:

An interview was conducted on 4/20/16 at 9:05 AM with Employee Identifier (EI) # 3, Psychiatrist, Medical Director Adult Psychiatric Unit. EI # 3 verified he provides on call services for the hospital. He stated when he came to work at the hospital, he was covering consults in the medical surgical areas of the hospital. EI # 3 verified the psychiatrists rotate taking after hours calls. He stated the responsibilities while on call include taking calls from the psych intake area of the Emergency Department (ED). He verified that when on call he had received calls from the ED physician and we (psychiatrists) refer them to the psych intake unit in the ED. He stated as far as he was informed, the psychiatrists do not go to the ED. The surveyor asked if he goes to the ED to assess patients or provide psych consults. He stated that the psychiatrists see them on the unit and if there are no beds in the unit, the patient is referred out of the facility. EI # 3 stated his responsibility related to providing psychiatric services in the ED, he takes calls from ED physicians and the psych intake staff.

An interview was conducted on 4/20/16 at 10:00 AM with EI # 5, Psychiatrist, Medical Director Geripsychiatric Unit, who verified the psychiatrists do not go to the ED for consultations.

An interview was conducted on 4/20/16 at 10:50 AM with EI # 7, Registered Nurse (RN) - ED Psych Intake. The surveyor asked if she had ever called the psychiatrist on call to come to the ED to evaluate a patient. She stated she had asked on one occasion, EI # 5 came down. She stated she only remembered one time since Horizon has been here and the ED was backed up and we were trying to get patients dispositioned. They told us it was not in the contract to see patients in the ED. When questioned if she had ever had to call the on call psychiatrist to discuss a patient over the phone, she stated only to receive admission orders. The surveyor asked if any of the psychiatrists come to the ED to evaluate patients. She stated not to her knowledge. The surveyor asked about the consult for the psychiatrist for PI # 2. She stated the patient had been denied admission to Hospital # 3. Apparently, the patient was on an outpatient commitment and this was the first time she had to deal with outpatient commitment. She stated the patient was on EI # 3's round list and the ED probably asked me to call EI # 3. She stated that even if the patient is on the psychiatrists' round list, they are not coming to the ED for rounds.

An interview was conducted on 4/20/16 at 4:10 PM with EI # 6, RN - ED Psych Intake. During this interview, EI # 6 verified the Horizon Psychiatrists do not come to the ED.

An interview was conducted on 4/20/16 at 6:41 PM with EI # 8, RN - ED Psych Intake. The surveyor asked about the consult that was placed for PI # 2. EI # 8 stated that Hospital # 3 would not take the patient, she called EI # 3 because the ED physician wanted a consult for the psychiatrist to come to the ED. She stated she called EI # 3 to come to the ED and he said, "No and that he did not come to the ED."

During the exit interview on 4/21/16 at 12:00 PM, EI # 9, President (of the Hospital) stated Horizon Psychiatrists do not perform consults in the ED. She stated the contract is very clear that it is for inpatient services only.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of the Medical Staff Rules and Regulations, facility policy, ambulance patient care report, medical record and interviews, it was determined the facility failed to provide a medical screening examination for Patient Identifier (PI) # 1, a patient who arrived at the facility by ambulance on 2/22/16 with chief complaint of combative behavior and dementia.

This affected 1 of 27 medical records reviewed and had the potential to negatively affect all patients who present to this facility's Emergency Department (ED).

Findings include:

Review of the Medical Staff Rules and Regulations
Adopted: August 9, 2013
Approved by the Board: September 16, 2013

Article X
Emergency Services:

10.1 General:

Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care...

10.2 Medical Screening Examinations:

(a) Medical screening examinations, within the capability of the Medical Center, will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Medical Center policies and procedures are defined as:

(1) Emergency Department;
(i) members of the Medical Staff with clinical privileges in Emergency Medicine;
(ii) other Medical Staff members; and
(iii) appropriately credentialed allied health professionals...

Review of facility policy:

Policy: Medical Screening Examination Policy
Approval dated: 4/6/16
Effective date: 12/1989
Review date: 4/6/2016, (prior date: 3/2010)

For individuals seeking treatment on hospital property, the facility will provide a medical screening examination conducted by a qualified medical person to determine if an emergency medical condition exists. Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening exam...

Medical Screening Examination Procedure

A. A qualified medical person, either a physician or licensed independent practitioner shall:

1) Conduct medical screening examination upon arrival.

2) Screen as follows;
a. Assessment of chief complaint;
b. Assessment of general appearance;
c. Attainment of vitals signs;
d. Evaluation of mental status;
e. Performance of an applicable Focused Physical Exam as indicated by clinical finding during the Medical Screening Examination...


Review of the ambulance Patient Care Report dated 2/22/16 for Patient Identifier (PI) # 1 revealed, "... Incident Note: Prior to leaving (Skilled Nursing Facility - SNF) MIMC (Mobile Infirmary Medical Center) was contacted to give a brief pt (patient) report. MIMC RN (Registered Nurse) stated they were on full diversion including psych diversion, and that (SNF) had not called in a report prior to going on diversion... I went back to speak with the Director of Nursing (DON) because we had not yet pulled out to see where they wanted to transport the patient. DON at (SNF) stated she called in a report to the psych intake. While with DON at SNF, I called back to MIMC to settle the issue and gave the phone to the DON so that they could talk it out. DON handed phone back to me and said to continue on to MIMC. Right after pulling into MIMC drive way dispatch notified us that MIMC called dispatch and said that we would not take the pt there because they were on full diversion and that a nurse would meet us in the ambulance bay to explain. Once in the ambulance bay, 2 MIMC RN's came to the truck and stated they had just gotten off the phone with SNF and to transport to Hospital # 2..."

The patient was transported to Hospital # 2 via ambulance.

Review of PI # 1's medical record from Hospital # 2 revealed the patient arrived via ambulance on 2/22/16 at 1:15 PM with a chief complaint of psychiatric evaluation in bilateral wrist restraints, which were released immediately.

Review of the History of Present Illness revealed the patient was sent to the ED (Emergency Department) for medical clearance for psychiatric evaluation. Report from the nursing home states that patient became angry and aggressive; was throwing things, yelling at staff, cussing, etc... is currently calm until... starts talking about the vents at the nursing home... states they owe... $30 and wants (his/her) money... whenever (he/she) talks about the events... becomes upset and begins to cuss here... easily calms down... denies any physical complaints other than chronic right shoulder pain...

The ED physician conducted a medical screening examination on 2/22/16 at 2:12 PM. The patient was oriented to person, place and time, no cranial nerve deficit, coordination was normal. GCS (Glasgow coma score) eye subscore 4, verbal subscore 5, motor subscore 6, normal moor and affect, behavior was normal, judgment and thought content were all normal. PI # 1's physical examination was unremarkable except bilateral below the knee amputations.

The ED physician documented the ED course/ plan included... denies homicidal or suicidal ideation. The counselor has seen and revaluated the patient and does not believe that there is a reason for admission. I concur... (patient) has been instructed to remain calm when discussing the money issue... states (he/she) will try.

The patient was discharged in good, stable condition to return to the SNF via ambulance on 1/22/16 at 5:14 PM.

Interviews:

An interview was conducted on 4/19/16 at 2:30 PM with Employee Identifier (EI) # 1, ED Registered Nurse (RN) who verified she was working on 2/22/16, the date of the occurrence. She stated the hospital was on diversion on 2/22/16. She stated she answered a call from the ambulance crew who were at the SNF and the SNF wanted to send a patient to the hospital's ED for psych evaluation. She stated the SNF nurse manager stated she had already called psych intake area, who had said "come on any way". EI # 1 stated she usually informs the ambulance crew to let the patient know we are on diversion and the wait may be a while. EI #1 informed EI # 2, Charge Nurse about SNF sending patient for psych evaluation. EI # 2 then called the SNF and spoke with someone. She then told me to call dispatch for the ambulance and let them know to go ahead and send the patient to Hospital # 2. EI # 1 stated as she was talking to dispatch, who told her to let the ambulance crew know to go ahead to Hospital # 2, the ambulance pulled up in the ambulance bay. EI # 1 stated she and EI # 2 went outside and informed the ambulance crew to go ahead a take the patient to Hospital # 2 and the ambulance left.

An interview was conducted on 4/20/16 at 1:31 PM with EI # 2, RN Charge Nurse (ED). EI # 2 stated she spoke with the Director of Nurses (DON) at the SNF and the DON said to let the ambulance know it was ok to send the patient to Hospital # 2, because we were on diversion. She stated she asked EI # 1 to call dispatch for the ambulance and let them know to divert to Hospital # 2. Dispatch told her to go ahead and let the ambulance crew know because they should be pulling up at their facility. EI # 2 stated she and EI # 1 walked out to the ambulance and dispatch was on the phone with the crew at the same time we told them to divert to Hospital # 2. The ambulance left our facility.

MIMC identified a possible EMTALA violation which occurred on 2/22/16 and self reported the possible violation to the Centers for Medicare and Medicaid (CMS) regional office in a letter dated April 1, 2016. MIMC initiated the following corrective measures for Patient Numbered 1:

"... Recommendations and Plan for Correction:
1. Investigation of incident... Completed 4/5/16
2. Two MIMC RNs (Registered Nurse) (Employee Identifier (EI) # 1 and EI # 2) received counseling - completed 3/1/16
3. MIMC ED (Emergency Department) staff completed the EMTALA Healthstream Module - completed 4/5/16.
4. MIMC ED staff, Security and Admissions received face to face education on EMTALA and Chain of Command - Completed 4/5/16
5. Team Health Physicians received EMTALA education via Minefield Navigator - completed 4/10/16

Monitoring:

The ED Manager, or her designee, will perform chart reviews on:

100% of LWBS (Left without being seen), AMA (Against Medical advice), Eloped and Transferred patients will be monitored monthly for 2 months. If 90% or greater compliance of documentation, we will then monitor 50% of above stated charts for 1 month, if 90% or greater compliance for one month we will move to random QA (Quality Assurance) monitoring for the Emergency Department...

An additional 30 charts per month (15 admits and 15 discharges) will be checked to assure that appropriate medical screening exams were initiated and documented. This will be audited for at least 3 months.

Any deficiencies from chart audits will result in face to face coaching with employee by the unit manager or her designee.

Calls for patients that need to be evaluated for possible psych admission no longer go through Psych intake for report. All calls will be routed through the Main ED for report..."

The State Surveyor confirmed EMTALA education and other educational corrective actions were completed by MIMC staff and physicians on 4/21/16.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Medical Staff Bylaws, facility policies, Services Agreement (contract), hospital census reports and medical records, it was determined the facility failed to provide stabilizing treatment for Patient Identifier (PI) # 2, a patient who (MDS) dated [DATE] for psychiatric evaluation and diagnosis of Suicidal Ideation (SI) with a history of Bipolar and Schizophrenia, which the facility had the capacity to treat.

This affected 1 of 27 medical records reviewed and had the potential to negatively affect all patients who present to this facility's Emergency Department (ED) with psychiatric complaints.


Findings include:

Review of the Medical Staff Bylaws
Revised and Adopted by the Medical Staff: June 17, 2013
Approved by the Board: September 16, 2013

Article 2

Categories of the Medical Staff

2. A Active Staff:

... 2.A.3. Responsibilities:

(a) Active staff members must assume all the responsibilities of membership on the Active Staff, including...

(2) providing specialty coverage for the Emergency Department;

(3) providing care for unassigned patients...

Review of facility policies:

Policy: Emergency Medical Condition Assessment Policy
Approval Date: 10/14/2013

Emergency medical conditions are those manifesting themselves by acute symptoms of sufficiency severity including severe pain, psychiatric disturbances, symptoms of substance abuse and/or women in labor such that the absence of immediate medical attention could reasonable be expected to result in:

1) Placing the health of the individual in serious jeopardy...

The use of ancillary services may be required to determine whether or not an emergency medical condition exists. The following conditions require additional consideration in assessment...

2) Intoxicated individuals - Some intoxicated individuals may meet the definition of an emergency medical condition if the absence of treatment places their health in serious jeopardy or results in serious impairment of bodily functions or serious dysfunction of a bodily organ.

3) Psychiatric Conditions - An individual at risk for harm to self or others or demonstrating disorganized or bizarre behavior that may lead to harm to self or others.

Procedure if an Emergency Medical Condition Exists:

1) Personnel should immediately begin stabilizing measures.

2) Emergency medical conditions must be stabilized within the capabilities of the hospital...

Policy: Medical Staff Coverage Emergency Department
Approval Date: 7/2/2013

Purpose: To establish a process for Emergency Department medical staff coverage.

Policy:

A. Patients admitted to the Emergency Department should be attended by a member of the Medical Staff of Team Health or the Medical Staff of Mobile Infirmary...

C. In the event a patient presents for treatment who has no attending physician, such patients should be assigned in accordance with the Unattached On-Call Physician (EMTALA) Schedule, after an evaluation by the Emergency Department physician to determine the medical specialist required for the patient's complaint and follow-up...

Review of the Services Agreement dated 4/14/14 between Horizon Mental Health Management and Mobile Infirmary Medical Center revealed:

"... Agreement: Pursuant and subject to the terms and conditions hereinafter set forth, Hospital hereby retains the services of Horizon to assist in the operation of a geropsychiatric inpatient programs and an adult psychiatric inpatient program by Hospital and Horizon agrees to provide the services necessary to assist in the provision of such psychiatric services by Hospital for the consideration specified herein (the "Program")...

... Covenants of Hospital

Hospital covenants and agrees that, at the Hospital's expense, Hospital shall:

... (m) Agree that licensed psychiatrists who are members of Hospital's medical staff may admit and practice in the Program, and that Hospital will maintain and implement a medical staff review procedure to address attending physicians' performance issues in accordance with Hospital medical staff bylaws...

... Covenants of Horizon

Horizon covenants and agrees that it shall:

... (c) Provide the Program staff as needed for the Program, including but not limited to, providing the following services... medical-administrative direction... The Horizon Program staff shall consist of the following personnel:

... Medical Director(s) Part-time Independent Contractor
Psychiatrist(s) Part-time Independent Contractor

Horizon's Medical Director responsibilities are limited solely to the provision of administrative services and not the provision of professional medical services, attending or coverage services in the absence of Program psychiatrists.

(d) With Hospital's prior approval, provide the physician resources necessary to operate the Program in accordance with all local, state and federal governing regulatory and licensure requirements as well as any Hospital-specific departmental rules and bylaws. Such physician resources shall include psychiatrists necessary to ensure admitting, discharge, daily rounds and after hours and weekend coverage are available to ensure full utilization of the Program...

V. Operation of the Program

It is agreed and understood that:

(a) The Program is a service provided by Hospital to Hospital's patients and ultimate control and supervision over the Program and its operation shall reside in Hospital. The Program shall be subject to the same monitoring and oversight by Hospital as is applicable to any other department of the Hospital...

(c) The medical staff committees of Hospital, such as quality assurance, utilization review and coordination and integration of services, shall be responsible for the medical services provided in the Program.

(d) The Medical Director of the Program shall report to the Chief Medical Officer (or similar official) of Hospital in the same manner as any other medical director of a department of Hospital and shall be subject to the same type of supervision and accountability as any other department medical director...

First Amendment to Agreement between Horizon Mental Health Management and Mobile Infirmary Association dated 6/1/15 revealed...

5. As of the Effective Date, Section VI, Horizon Fees, paragraph (c) Pass-Through Expenses, is deleted in its entirety and replaced with the following:

(c) Pass-Through Expenses... Hospital shall also pay to Horizon any reasonable costs related to Horizon's use of External Physician Coverage such as locum tenens, mid-level/physician extenders (e.g., Nurse Practitioners and Physician Assistants), or any other External Physician Coverage required to operate the Program as agreed to in advance by the parties...

Review of the medical record for PI # 2:

PI # 2 presented to the emergency department (ED) on 11/25/15 at 5:33 PM via ambulance for psychiatric evaluation.

Review of the 11/25/15 at 5:55 PM ED Notes revealed the Registered Nurse (RN) documented the patient was brought to the ED via EMS (Emergency Medical Services) with diagnosis of Suicidal Ideation (SI) with a history of Bipolar and Schizophrenia, had been drinking for 4 days and had not taken (his/her) medications for the entire time.

Review of the RN Note dated 11/25/15 at 6:36 PM revealed the patient presented to the ED via ambulance with complaints of suicidal ideation without a plan, homicidal ideation (HI) toward his/her father. PI # 2 denied visual hallucinations (VH), but was positive for audio hallucinations (AH), stating the "voices are telling me to kill myself". The patient had a history of Schizoaffective disorder and had not taken psychiatric medications for 4 days while drinking for 4 days. The patient was vomiting in the ED at the time. PI # 2 requested to be hospitalized at Hospital # 3. PI # 2's case was discussed with the physician.

Review of the Medical Screening Examination for PI # 2 dated 11/25/15 at 8:39 PM by the ED physician revealed:

Review of Systems: Psychiatric/Behavioral: Positive for suicidal ideas, dysphoric mood and agitations. All other systems reviewed and are negative. Patient History: Medical History: ... past medical history of Depression; Bipolar 1 disorder, depressed; Morbid obesity, Marijuana abuse, Suicidal ideation; and Homicidal ideation... Social History: ... reports (he/she) drinks alcohol... uses illicit drugs (Marijuana)...

Physical Exam: ... Constitutional: .... oriented to person, place and time... appears well-developed and well-nourished... Psychiatric: Judgment and thought content normal. Flat affect, disheveled...

Review of the lab results for Urine drug screen revealed PI # 2 was positive for cannabinoid (normal for this facility - negative) and urine Alcohol level was 191 {normal for this facility is less than 10 mg/dL (milligrams/deciliter)}. All other components were within normal limits.

Review of the lab results for CBC (complete blood count) revealed the patient's Hemoglobin was 12.9 (Normal for this facility: 14 to 18 gm/dL - grams/deciliter), Lymphocytes - automated 44 (normal for this facility 20 - 40 %). All other components were within normal limits.

(Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs. Lymphocytes are responsible for immune responses. www.medicinenet.com).

Comprehensive Metabolic Panel (CMP) revealed the patient's Glucose 102, {normal for this facility is 70-99 mg/dl (milligrams/deciliter)} and Albumin 3.4 (normal for this facility 3.5-5.0 gm/dL). All other components were within normal limits.

(CMP is a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function. Albumin is a protein in the blood, which helps keep blood from leaking out of the blood vessels and helps carry some medicines and other substances through the blood and is important for tissue growth and healing. www.webmd.com)

Review of the RN documentation on 11/25/15 revealed the following:

9:31 PM - the (patient's) chart was sent to Hospital # 3 and was awaiting call from them.

10:46 PM - Hospital # 3 called and was unable to accommodate the patient at that time and stated the referral may be revisited in the morning. The patient was also denied admission into this facility's psychiatric unit related to alcohol intoxication per Employee Identifier (EI) # 4, Psychiatrist. The patient's case was discussed with the ED physician at that time.

11:48 PM - the patient was resting comfortably at that time and a sitter was present at bedside.

Review of the RN documentation on 11/26/15 revealed at 1:16 AM and 3:05 AM the patient was resting comfortably and a sitter was present at the patient's bedside.

Review of the RN documentation on 11/26/15 revealed the following:

3:25 AM - the patient stated he/she needs help; explained to the patient that neither the physician here or at Hospital # 3 would be able to accommodate him/her this evening; the patient was requesting to go home and the case was discussed with the physician at that time.

4:00 AM - the patient was resting with no distress.

4:18 AM - Due to the patient being denied admittance to Hospital # 3 and MI (Mobile Infirmary) Psych unit, ED physician has requested that psych intake contact EI # 3, Psychiatrist on call to request a psychiatrist consult in the ED.

Review of the Physician Consult Order dated 11/26/15 at 4:22 AM revealed orders for a one time physician consult for EI # 3, Psychiatrist due to the patient being denied admittance to two psych units, but the patient still claimed to be suicidal. The order priority was STAT (A common medical abbreviation for urgent or rush) and was referred to EI # 3.

5:49 AM - the patient was resting with no distress.

9:06 AM - the patient was agitated during interview this morning. Maintains that he/she is suicidal and wants to hurt father. states... is on outpatient commitment for multiple things and is seeing (Mental Health) for therapy and out patient services. States last appointment is for December 1st. The patient's mother stated she filed probate in August. Called (Access center for Hospital # 3) and discussed the patient and will fax the patient's chart again. The patient's alcohol level is zero this morning.

9:34 AM - Called 5 SE (Southeast - Adult Psychiatric Unit), 5W (West - Geripsychiatric unit) and EI # 3's number to discuss ED consult placed for the patient to help with disposition. The RN was unable to get in touch with EI # 3 at that time. PI # 2 was listed on EI # 3's rounds list. Will continue to try to contact (EI # 3).

10:04 AM - Spoke with EI # 3 and updated him on this patient. EI # 3 does not make rounds in the ER (emergency room ). EI # 3 stated that if patient violated out patient commitment that Hospital # 3 is supposed to take the patient. Discussed with (named person) at (Access center for Hospital # 3). (Named person) to discuss with (named psychiatrist at Hospital # 3). Awaiting return call.

10:36 AM - Patient medically stable to transfer per ED physician. Patient accepted at Hospital # 3 per psychiatrist for Hospital # 3.

The patient was transferred to Hospital # 3 on 11/26/15 at 11:30 AM.

Review of the Discharge Summary from Hospital # 3 for PI # 2 revealed the patient was voluntarily admitted to the facility on [DATE] with Schizoaffective disorder, Alcohol use disorder, Cannabis use disorder, Impulse control disorder, family relation problems and obesity. Reason for admission revealed the patient was under an outpatient commitment with the Bridge Team (outpatient therapy). The patient presented to the hospital from MIMC (Mobile Infirmary Medical Center) with suicidal ideation with no plan.

Hospital Course included: "... Axis I: 1. Schizoaffective disorder, 2. Alcohol use disorder, 3. Cannabis use disorder, 4. Impulse control disorder, 5. family relation problems 6. obesity. The patient was given this diagnosis because of (his/her) previous multiple presentations to psychiatric hospital as well as (his/her) presentation on recent admission where he/she admitted having spent $200.00 of father's money for drinking alcohol and said he/she wanted to get straight. Initially PI # 2 presented with SI (suicidal ideation) as well as HI (Homicidal ideation) towards father. We started PI # 2 on previous medications Trileptal 300 mg (milligrams) twice a day (bid) and Geodon 80 mg bid, the patient continued to have passive death wishes, denied active SI/HI. The patient had an outburst during a telephone call with the parents and phone restrictions were ordered. Two days later phone restrictions were lifted and the patient did great on that. On admission the patient endorsed AH (auditory hallucinations), which later resolved. The patient's mood slowly improved over the hospital stay. Upon discharge, the patient denied AH/VH or other psychotic symptoms like paranoia. The patient denied SI/HI and was deemed safe for discharge..."

Review of the Census report dated 11/25/15 at 12:00 AM revealed there were 13 patients inpatient on 5 South East (Adult Psychiatric Unit) with 1 male bed available. Review of the Daily Unit Census Report dated 11/26/16 at 5:42 AM revealed the same 13 patients were listed as being inpatient on 5 South East, with 1 male bed available to admit PI # 2.

MIMC identified a possible EMTALA violation which occurred on 2/22/16 and self reported the possible violation to the Centers for Medicare and Medicaid (CMS) regional office in a letter dated April 1, 2016. MIMC initiated the following corrective measures for Patient Numbered 1:

"... Recommendations and Plan for Correction:
1. Investigation of incident... Completed 4/5/16
2. Two MIMC RNs (Registered Nurse) (Employee Identifier (EI) # 1 and EI # 2) received counseling - completed 3/1/16
3. MIMC ED (Emergency Department) staff completed the EMTALA Healthstream Module - completed 4/5/16.
4. MIMC ED staff, Security and Admissions received face to face education on EMTALA and Chain of Command - Completed 4/5/16
5. Team Health Physicians received EMTALA education via Minefield Navigator - completed 4/10/16

Monitoring:

The ED Manager, or her designee, will perform chart reviews on:

100% of LWBS (Left without being seen), AMA (Against Medical advice), Eloped and Transferred patients will be monitored monthly for 2 months. If 90% or greater compliance of documentation, we will then monitor 50% of above stated charts for 1 month, if 90% or greater compliance for one month we will move to random QA (Quality Assurance) monitoring for the Emergency Department...

An additional 30 charts per month (15 admits and 15 discharges) will be checked to assure that appropriate medical screening exams were initiated and documented. This will be audited for at least 3 months.

Any deficiencies from chart audits will result in face to face coaching with employee by the unit manager or her designee.

Calls for patients that need to be evaluated for possible psych admission no longer go through Psych intake for report. All calls will be routed through the Main ED for report..."

The State Surveyor confirmed EMTALA education and other educational corrective actions were completed by MIMC staff and physicians on 4/21/16.