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.

CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL 7700 S BROADWAY LITTLETON, CO 80122 Sept. 26, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A 2406 Medical Screening Examination
The facility failed to ensure that patients were provided an appropriate medical screening examination (MSE).

Tag A 2409 Appropriate Transfer
The facility failed to ensure that patients were afforded an appropriate transfer.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility document review and staff interview the facility failed to ensure that patients were provided an appropriate medical screening examination (MSE).

This failure has the potential to lead to patient harm due to not receiving the appropriate MSE and possible necessary treatment or therapies.

Findings:

1. The facility failed to ensure that Sample Patient #1 received an appropriate MSE. This patient was seen by an Emergency Department (ED) physician who determined the patient was at risk due to his suicidal ideation and violent behavior. A mental health (M1) hold was placed and evaluation by the psychiatric team ordered but was never completed. The patient was discharged with law enforcement to jail due to his violent behavior.

a. A review of the medical record for Sample Patient #1 revealed s/he was brought into the ED on 07/05/12 at 3:23 a.m. by ambulance and police in 4 point restraints due to belligerent and assaultive behaviors. The Patient admitted to drinking alcohol and smoking marijuana. The Emergency Medical Services (EMS) report to the receiving RN was that the Patient stated "you leave me I'll kill myself." The nursing note indicates the Patient stated to the RN "My parents are going to kill me."

Upon arrival to the ER, s/he was temporarily released from restraints after the RN talked to him/her and advised him/her if s/he cooperated they would not be put back on. S/he was administered Ativan 2 mg IV push on three occasions for aggressive behavior. An order was written at 3:32 to notify the psychiatric evaluation team about the Patient. An order for 4 point restraints was also written. During the process of placing the restrains, the Patient kicked an ED tech in the face, was spitting and attempting to bite the RN. The mental health hold (M1) process was initiated at 4:13 a.m. per physician order . The police department was notified at this time regarding Patients assaultive behavior.

At 4:25 a.m. the nursing notes stated the Patient was sleeping and being prepared to be discharged to jail. His/her blood alcohol level was 298. The Patient had not received a psychiatric evaluation.

The discharge summary written by the ED physician states the Patient's work up was consistent with alcohol intoxication, possible polypharmacy ingestion or acute exacerbation of mental illness. "S/he did seem to understand his/her actions and demonstrated medical decision making capacity and I feel s/he is to be held responsible for assaultive behavior toward nursing staff". The note also stated that the Patient was medically cleared for jail without any obvious evidence of needing further emergency medical management and "can continue to sober in jail where s/he is safe and unlikely to present further harm to others."

The Patient was discharged at 4:59 a.m. in the custody of law enforcement, ambulating and in hand cuffs. ED Physician's discharge instructions stated to place the Patient on suicide watch and obtain psychiatric evaluation in jail.

b. An interview was conducted on 09/25/12 at 1:58 p.m. with the ED Director (EDD), ED Manager, and Director of Quality Management (DQM). The EDD stated that a process has been implemented for psychiatric patients who are abusive and threatening to the ED staff. These patients may be taken off of the M1 hold either before or after they have been evaluated by the psychiatric team and discharged to jail. They are sent with an order by the ED physician as being a suicide risk and to have a psychiatric evaluation by the psychiatric evaluation team . S/he states this only happens if the patient is medically stable, has failed attempts at de-escalation and is harmful to ED staff.

c. An interview was conducted on 09/26/12 at 8:25 a.m. with the EDD where s/he wanted to provide some background to the decision of sending violent patients to jail. S/he stated they have been seeing a lot more violent and dangerous patients and there have been several incidents of staff members being attacked by violent patients. Last summer the hospital administration, risk management, and legal counsel met with local law enforcement and a city attorney to discuss what their options were for handling violent patients. The conclusion was to discharge the patients into the custody of the police and they would ensure a psychiatric evaluation would still be obtained. The hospital's contracted psychiatric evaluation team does evaluations at the jail as well, so the physicians could use the jail as another resource to treat these patients.

d. The ED Medical Director was interviewed on 09/26/12 at 8:50 a.m. S/he stated the patients that are discharged to jail are medically stabilized and the only thing left to be handled is their psychiatric condition. Evaluations and continued treatment can be handled in jail. The Medical Director stated a policy was revised and approved by medical staff last summer regarding violent patients.

e. An interview was conducted on 09/26/12 at 8:43 a.m. with the Patient's ED physician where s/he verified documentation in the medical record. S/he stated that because of the Patient's escalating behavior and aggression toward staff s/he decided to discharge the Patient to law enforcement. The Patient denied and showed no signs of physical trauma other than abrasions obtained during the earlier struggle with police. S/he felt that the Patient could get the psychiatric evaluation and care s/he needed in a safer place.

f. The RN for the Patient was interviewed on 09/26/12 at 9:20 a.m. where s/he verified documentation in the medical record. S/he stated the patient came in by ambulance with altered mentation from alcohol and marijuana. S/he was verbally abusive from the time of arrival. His/her behavior continued to escalate and become more violent despite being medicated with Ativan and physically restrained. S/he stated the patient made no suicidal comments but did state that his/her parents were going to kill him/her. When the patient became violent the RN called law enforcement and they arrived on scene very quickly. S/he was discharged to them on a suicide watch and was to have a psychiatric evaluation in jail.

g. Hospital policy "Patients on Involuntary Status", last revision 07/2011 was reviewed.
It states in section VII: staff members may press charges against a patient, who is alleged to have physically harmed patient care personnel and or has caused hospital property damage. The attending physician must ensure that the patient is medically stable for transfer to local law enforcement facilities or to another healthcare entity with appropriate facilities in accordance to these Rules and Regulations and applicable policies. Further, if the patient is on a mental health hold, the physician shall be responsible for relinquishing that patient from the mental health hold in order for local law enforcement to place the patient on a suicide watch.

h. Hospital policy "EMTALA" was reviewed. Its defines emergency condition (EMC) as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. The policy states the hospital shall provide a medical screening examination (MSE) to determine whether an EMC exists. It defines a MSE as the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist. The MSE represents a spectrum ranging from a brief history and physical exam to complex processes that also involve performing ancillary studies and procedures. The policy states the MSE is an ongoing process. The medical record must reflect an ongoing assessment of the patient's condition. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer. The policy defines a Qualified Medical Person as an individual who is licensed or certified in one of the following professional categories and who has demonstrated current competence in the performance of a MSE: all staff physicians, ED mid-level practitioners, PEPCS team members (psychiatric evaluators) and obstetrical nurses.

2. The facility failed to ensure that Sample Patient #2 received an appropriate MSE. This patient was seen by an ED physician who determined the patient was at risk due to his suicidal ideation and violent behavior. A M1 hold was placed and evaluation by the psychiatric team ordered but was never completed. The patient was discharged with law enforcement to jail due to his violent behavior.

a. Sample Patient #7 (MDS) dated [DATE] at 9:12 a.m. S/he was brought into the ED by EMS after an altercation with his/her spouse and then voiced suicidal ideation. The Patient received several doses of Haldol due to aggressive behavior and was also intermittently in 4 point restraints. A M1 hold and psychiatric evaluation was ordered for the Patient by the ED physician. The Patient was in the ED until s/he was discharged to law enforcement at 4:55 p.m. due to threatening and assaultive behavior. The patient did not receive a psychiatric evaluation before discharge.

b. During an interview with the DQM on 09/26/12 at 12:03 p.m. it was verified that Sample Patient #7 was a patient with suicidal ideation who did not receive a psychiatric evaluation and was discharged to jail.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on medical record review, staff interview, and facility document review the facility failed to ensure that patients were afforded an appropriate transfer.

This failure has the potential to lead to patient harm from inappropriate coordination of necessary further stabilizing treatment needed for patients.

Findings:

1. The facility failed to ensure that Sample Patient #2 was transferred appropriately. The hospital had performed a medical screening examination and determined that the patient needed specialized psychiatric care that could not be provided at the hospital. The hospital could not find placement for the patient after 2 days. The patient was then discharged with law enforcement to jail.

a. A review of Sample Patient #2's medical record revealed that on 07/06/12 at 11:37 a.m. the patient presented to the hospital's Emergency Department (ED). The patient was seen by the ED physician and received a psychiatric evaluation by the hospital's psychiatric evaluator. Based upon the examinations the record indicated that the patient was determined to be a danger to himself/herself and others. The treatment team all felt that inpatient hospitalization was needed for the patient. However, over the following days the hospital could not locate a psychiatric hospital that could/would admit the patient. The patient remained in the ED requiring restraints and medication frequently to address his/her violent outbursts and property destruction. The hospital staff contacted local law enforcement on 07/08/12 at 4:30 p.m. and at 5:30 p.m. The patient was then discharged to jail at 6:30 p.m. The physician dictation from the treating physician on 07/08/12 at 6:01 p.m. stated that "after discussion with [ED Medical Director], it was felt that the patient was more threatening and that we should simply just call the police and have him/her arrested and drop the mental-health hold and place him/her on a suicide watch because s/he is at risk for harming staff members."

b. An interview was conducted with the facility's ED Medical Director on 09/26/12 at 8:51 a.m. S/he stated that the hospital had been faced with the choice to either restrain Sample Patient #2 "forever or have him/her placed in a jail cell." We could either restrain him forever or have him placed in a jail cell. S/he stated that the patient did need further treatment that could not be provided by the hospital. "We have a policy regarding violent patients that was developed that was approved by the medical staff." "This is an example of a problem with the system. S/he was stabilized, we transferred him/her, not because of convenience, but because s/he showed that s/he was a danger to staff with his/her chronic condition and we needed to transfer him/her to a facility that could keep him/her safe and provide him/her a psychiatric evaluation."

c. An interview was conducted with the facility's ED Nursing Director on 09/26/12 at 8:25 a.m. S/he stated that the hospital had over the past year become more concerned regarding staff injuries from patients assaulting staff members. S/he stated that in response the hospital had gathered staff from risk management, law enforcement, and hospital administration to discuss the hospital's options. S/he stated that the facility had come to the conclusion that the hospital could "discharge patients in the custody of police and would ensure that they could still get psychiatric evaluations." S/he stated that the mental health center for the county already performed psychiatric evaluations for incarcerated individuals in the jail and they had agreed to do so for patients sent by the hospital that needed evaluations while incarcerated. S/he stated that these were not treated like an EMTALA transfer by the facility and thus did not have standard documentation and coordination as was done with transfers to other facilities.

d. A review of the hospital's Medical Staff Rules and Regulations, last amended 04/19/12, revealed that there was a section titled "Protection of Mentally Unstable Patients" which stated the following:
"For the protection of patient, the Medical Staff, patient care personnel and the Hospital, precautions to be taken in the care of the potentially suicidal patient include:
a. If there are no appropriate accommodations in the Hospital, the patient shall be referred, if possible, to another institution where suitable facilities are available.
b. When transfer is not possible, the patient may be admitted to a general area of the Hospital and as a temporary measure, bars or locks may be placed in the windows of the patient's room and/or special nursing supervision provided. Such patients should spend daytime hours in the area where special observation and therapy are available, if possible and, as a temporary measure, be placed in a security room.
c. Any patient known to be suicidal should have consultation by a member of the psychiatric staff and the patient care staff should be notified by a note on the order sheet."

e. A review of the hospital's policy titled "EMTALA - Emergency Medical Treatment and Active Labor Act", last revised 05/21/12, revealed that the policy restated the requirements of this section and other portions of the EMTALA regulations verbatim. The policy used the definition of an Emergency Medical Condition that is the regulation and interpretive guidance. Additionally, the policy required transfers to be made in an appropriate manner as described in this regulation and interpretive guidance.

f. A review of the hospital's policy titled "Patients on Involuntary Status", last revised 07/11, revealed that the policy expected facility staff to transfer patient's placed on an involuntary hold to another facility and follow the facility's EMTALA policy. Additionally, the policy stated that a mental health hold could be released by a licensed independent practitioner (LIP) if after observation of the patient that the patient has improved. The policy contained a section titled "Pressing Charged for Assault and/or Property Damage" which stated:
"Individual hospital staff and/or Allied Health/ Medical Staff Members may press charged against a patient, who is alleged to have physically harmed patient care personnel and/or has caused property damage disrupting hospital operations. The admitting/attending physician must ensure that the patient is medically stable for transfer to local law enforcement facilities or to another healthcare entity with appropriate facilities in accordance with these Rules & Regulations and applicable policies. Further, if the patient is on a mental health hold, the Medical Staff Member shall be responsible for relinquishing that patient from the mental health hold in order for local law enforcement to place the patient on a suicide watch."

2. The facility failed to treat the transfer of Sample Patient #6 to another facility as a transfer. The facility placed the patient on an Emergency Commitment (Mental Health Hold) and sent the patient to another facility for further stabilizing care.

a. A review of the medical record of Sample Patient #6 revealed that the patient presented to the hospital's ED on 06/15/12 at 9:45 a.m. The patient was brought into the ED by ambulance after the patient's parents had contacted 911 due to concern that the patient had used "bath salts" and was reportedly "out of control" and "acting in a psychotic fashion." The patient received medications from ambulance personnel to attempt to control the patient's psychotic behavior. The patient arrived to the ED in a "comatose state." The ED physician had documented that the patient had been placed on ain involuntary hold of 5 days and was felt to be a danger to himself/herself and others. The patient was transferred to a facility where the patient would be further evaluated and treated prior to discharge. The record did not contain documentation of the EMTALA transfer process and no documentation of coordination between medical staff and receiving facility medical staff was present in the record. The ED physician did not document the risks and benefits of transfer or provide physician certification of the patient's condition and need for transfer.

b. An interview with the hospital's ED Case Manager was conducted on 09/26/12 at 11:48 a.m. S/he stated that the hospital staff "never" completed EMTALA paperwork for patients that went to the detoxification facility that Sample Patient #6 was transferred to. S/he stated that the patient was sent to the facility involuntarily and that the patient was sent on a mental health hold. S/he stated that the patient was taken to the facility by staff from the receiving facility.

3. The facility failed to ensure that required documentation was completed for Sample Patient #4 when the patient was transferred to another hospital for further stabilizing treatment.

a. A review of the medical record of Sample Patient #4 revealed that on 07/08/12 the patient presented to the hospital's ED with alcohol intoxication and possible suicide attempt. The patient remained in the ED until s/he had reached a level of sobriety to have a psychiatric evaluation. The patient was determined to be a danger to himself/herself and was transferred to a psychiatric hospital. A review of the hospital's "Physician Assessment and Certification for Transfer" form revealed that the area in which the physician was to document the patient condition was blank as was the section in which the risks and benefits of the transfer were to be documented as having been discussed with the patient.

b. An interview was conducted with the hospital's Director of Quality on 09/26/12 at 9:17 a.m. S/he confirmed that the form for Sample Patient #4 was missing the aforementioned information. S/he stated that s/he would check with the Director of the ED to see if the information was documented elsewhere in the record. A subsequent interview on 09/26/12 at 10:50 a.m. revealed that the Director of the ED had relayed to the Director of Quality that the form was incomplete and that the sections mentioned above should have been completed by the physician.