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.

MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER 4700 WATERS AVENUE SAVANNAH, GA 31403 Aug. 30, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of the Central Log, medical records, policies and procedures, hospital B's medical record, Daily Transfer Log, Diversion Tracking Log, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Professional Services Agreement, ED staffing, Pod D census, Performance Corrective Counseling data, observations, personnel and credential files, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) individual (patient #2) of twenty (20) sampled patients when the patient presented to the ED via Emergency Medical Services (EMS) on 04/17/16.

Findings:

1. Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) for patient #2 on 04/17/2016.

2. Cross refer to A2407 as it relates to failure to provide appropriate stabilizing treatment for patient #2 on 04/17/2016.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Central Log, medical records, policies and procedures, hospital B's medical record, Daily Transfer Log, Diversion Tracking Log, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Professional Services Agreement, ED 00, Pod D census, Performance Corrective Counseling data, observations, personnel files, credential files, and facility's corrective actions, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) individual (patient #2) of twenty (20) sampled patients when the patient presented to the ED via Emergency Medical Services (EMS) on 04/17/16.

Findings:


Review of the ED Central Log and patient #2's record revealed that the patient was brought to the ED on 04/17/16 at 5:47 a.m. by EMS. The EMS report revealed that the ambulance attendants responded to a [AGE]-year-old patient who was complaining of suicidal ideations (thoughts of committing suicide). The report revealed the ambulance attendants arrived on the scene and found the patient "out" with a police officer. The report further revealed that the patient was having thoughts of harming himself/herself and that the patient had superficial cuts on his/her wrist. The report noted that the patient had a history of psychological behavior and manic (state of extreme periods of euphoria) and depressive (periods of extreme emotional lows) behavior. In addition, the report revealed the patient wanted to be taken to the hospital. The report revealed the patient was received by Memorial Health University Medical Center's (MHUMC) Registered Nurse (RN) #2 and that the nurse signed that he/she had received the written EMS report.

Further review of the patient's medical record revealed that the patient arrived in the ED on 04/17/16 at 5:47 a.m. by ambulance, escorted by police. Documentation revealed that the patient's chief complaint was anxiety and that the patient was triaged (assessment by a nurse to determine the priority in which patients will be seen by the provider) as a non-urgent patient.

Review of the facility's policy entitled Triage, policy number ED136, last revised 01/2016, effective 06/2016, revealed that the facility utilized Emergency Severity Index (ESI) five (5) level triage system. The ESI system defined the five (5) levels as follows:
--level 1 immediate life-saving (the facility's computer system revealed these patients were critical);
--level 2 high risk for rapid deterioration (the facility's computer system revealed these patients were emergent);
--level 3 required two (2) or more resources (the facility's computer system revealed these patients were urgent);
--level 4 required only one (1) resource (the facility's computer system revealed these patients were non-urgent); and
--level 5 required no resources (the facility's computer system revealed these patients were minor).
The Job Aid attached to this policy noted that an example of level 2 patients included those with suicidal or homicidal ideations.

Review of the facility's policy entitled Evaluation and Admission of Psychiatric Patients, policy #ED133, last revised 01/2016, effective 06/2016, revealed that the policy was to ensure quality mental health care for the patient with psychiatric and addictive disorders. This policy required patients to be provided with an appropriate evaluation to determine the need for admission to a psychiatric facility. This policy defined Pod D as the area designated in the ED for mental health patients. The policy was that patients were to be triaged per policy number #ED136 (the above policy) and noted that suicidal or homicidal patients were to be triaged as level 2 patients. This policy required patients in Pod D to be placed on elopement precautions.

Patient #2's medical record revealed that the Consent for Medical Treatment was signed on 04/17/16 by patient #2; there was no time noted on the form. The patient's documented past medical history included chronic back pain, chronic left shoulder pain, alcohol abuse, and opiate (narcotics such as heroin, methadone, codeine, and morphine) addiction. Documentation revealed that the patient was placed in room D03/A on 04/17/16 at 6:03 a.m. At 6:09 a.m., RN #2 noted that after being brought to the facility by a local police department officer, the patient changed his/her mind about wanting to be seen. The nurse noted that the patient ran through the nurses' station and out the door ( the door that exits the nurses' station into the ambulance bay hallway). The nurse noted that the police officer brought the patient back into the ED and reported that the patient was not a '1013' (Georgia's law that allows a patient to be held involuntarily when they are a threat to self or others) and that the patient had presented to the ED willingly to be evaluated. The RN further noted that the patient adamantly requested to leave, stating that he/she did not want or need to be seen and that coming to the ED had been the wrong answer. Nurses' notes revealed that the RN completed the Columbia-Suicide Severity Rating Scale at 6:08 a.m. The nurse noted that the patient denied wishing he/she were dead or having any thoughts of killing himself/herself for the past month. In addition, the nurse noted that the patient denied ever trying to end his/her life. Further documentation revealed that the patient left without being seen (LWBS) and was discharged home in stable condition on 04/17/16 at 6:15 a.m. There was no documented evidence that the ED physician had been informed of the patient's decision to leave or that the Patient Leaving the ED form #9611 had been completed.

Review of the nearby hospital's (hospital B) medical record for patient #2 revealed that the patient was admitted to their ED on 04/17/16 at 6:37 a.m. Documentation revealed that the patient's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) were within normal limits, and the patient was triaged as a non-urgent patient. Nurses' notes indicated that the patient was placed on suicide precautions. The patient was evaluated at 7:33 a.m. by a physician who noted that the patient was depressed, had suicidal thoughts and attempts, and that the patient had injuries to both wrists. The physician further noted that the patient had no previous suicide attempts. Orders included but were not limited to the following: blood work, urine drug screen, Ativan (used to treat anxiety) 1 milligram (mg) by mouth was order and administered four(4) times, Geodon (used to treat psychotic disorders) 20 mg intramuscularly was ordered and administered twice. Nurses' notes revealed that the patient received the Ativan as ordered on [DATE] at 8:21 a.m., 9:14 a.m., 11:30 p.m., and on 04/18/16 at 8:49 p.m. Nurses' notes revealed that the patient received the Geodon as ordered on [DATE] at 10:43 a.m. and on 04/18/16 at 8:53 p.m. Review of the lab results revealed that the patient tested positive for cocaine use. The psychiatric counselor's notes indicated that the patient did not want inpatient psychiatric treatment, that the patient was manipulative, and that the patient was at extreme risks for self-harm. The physician signed the 1013 form and began trying to transfer the patient to a psychiatric facility. The physician noted that there was difficulty finding an accepting facility that had an available bed. The physician's clinical impressions of the patient were: suicidal attempt, cocaine use, and superficial self-injuries to both wrists. On 04//19/16 at 2:11 a.m., the transfer form revealed the patient was accepted to a psychiatric facility by an accepting physician. Documentation revealed that the police transported the patient to the accepting psychiatric facility.

Review of the facility's policy entitled Patient Care Routine Guidelines, policy #ED139, last revised 01/2016, effective 06/2016, revealed that a withdrawal for medical request form was required to be completed if a patient was signing out Against Medical Advice (AMA) or had eloped and referenced "Refer to Leaving Hospital Before Discharge, policy #PC-5026". This policy also required that patients leaving without being seen, either before or after triage were to be informed of the risks of leaving and the Patient Leaving the ED form #9611 was to be completed and signed by the patient. The staff were required to document the disposition as LWBS and to discharge the patient from EPIC (the facility's electronic medical record system). This policy referred to policy #PC5026 Leaving Hospital Before Discharge.

Review of the facility's policy entitled Leaving Hospital Before Discharge, policy #PC-5026, last revised 08/2015, effective 10/2015, revealed that the policy was to ensure that patients received counseling and that there be documentation recorded when patients leave against medical advice (AMA). This policy defined Withdrawal of Request for Medical Care (LWBS) as those patients who leave the hospital before having an MSE. This policy required the following:
1. If a patient expresses a desire to leave the hospital prior to the discharge by a physician, explain the consequences of such act, (e.g., if the patient chooses to leave the hospital without a physician-ordered discharge, the patient is doing so at his/her own risk.)
2. Notify the patient's primary physician of the patient's desire to leave the hospital.
3. If the patient is not medically stable, explain the risks to the patient either in person or by phone.
4. If there is a question as to the decision-making capacity of the patient or guardian of a minor child, contact a case manager or psychiatric assessment team member, and nurse manager as soon as possible.
5. If the patient verbalizes understanding of the medical risks of leaving AMA and has Decision Making Capacity, complete the Patient Leaving the Hospital form #9634 and ask the patient to sign it. If the patient refuses to sign the form, document the risks discussed and that the patient refused to sign the form. Get a second team member to witness.
6. Document the patient's stated reason for wanting to leave AMA, who counseled the patient, what counseling was given to the patient, the time the patient left, and the patient's medical condition at discharge.

Review of facility policy entitled Emergency Medical Screening, Stabilization, Treatment & Transfer, policy #PC1019, last revised 10/2015, effective 04/2016, revealed it was the facility's policy that any individual who comes to the ED or Labor and Delivery requesting examination or treatment shall be provided with an appropriate medical screening examination without regard to diagnosis, financial status, race, color, national origin, or handicap. This policy noted that the examination was to be conducted by qualified personnel in accordance with the facility's Medical Staff Bylaws, and Rules and Regulations. This policy required the following steps if a patient withdrew his/her request for examination or treatment:
--explain that further medical examination and treatment might be required to identify and stabilize the emergency medical condition;
--inform the individual of the benefits of the examination and treatment and the risks of not receiving the examination and treatment; and
--ask the individual to sign the Patient Leaving the ED form #9611. If the individual refused to sign the form the staff was to document the discussion with the individual.


Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, signed by the Medical Staff President on 07/28/16, and pending approval by the Chair of the Board of Directors. Article II, Section 6. Medical Screening Examination required:
A. Any individual who comes to the Medical Center ED requesting examination or treatment shall be provided with an appropriate MSE. The purpose of the MSE is to determine if the individual is experiencing an emergency condition.
B. An MSE may be performed by a physician or resident physician. In the case of a pregnant woman, the MSE may also be conducted by a Labor & Delivery RN in consultation with a physician with appropriate clinical privileges.

Review of the Professional Services Agreement for the Emergency Physicians made and entered into on 12/31/2014 to be effective 01/01/14, revealed physicians on duty in the ED shall be responsible for examining and/or treating all persons who present themselves for care and/or treatment at the ED and providing, or causing to be provided, to such persons, medical treatment which may be necessary, in accordance with sound medical practice. In addition, revealed the "Group" (contracted physicians) agreed that all emergency medical services provided pursuant to the agreement shall be performed in compliance with all applicable standards set forth by law or ordinance or established by the rules and regulations of any federal, state or local agency,department, commission, association or other pertinent governing, accrediting, or advisory body, including the Joint Commission ("Joint Commission"), having authority to set standards for health care facilities, including compliance with the COBRA (consolidated omnibus budget reconciliation act) / EMTALA (Emergency Medical Treatment and Labor Act) laws, rules, and regulations.

On 08/29/16 at 11:45 a.m. in the ED Education Room, patient #2 listed place of employment was called and the operator reported that the business did not have an employee by patient #2's listed first or last name.

On 08/29/16 at 11:50 a.m. and 11:55 a.m. in the ED Education Room, two (2) attempts were made to reach patient #2 at the patient's listed home telephone number. During both calls, a voicemail with return call information was left for the patient.

On 08/29/16 at 12:40 p.m. in the ED Education Room, a call was made to the police department (PD) where officer #6 was employed at the time of the incident. Per the PD, the officer was no longer with that department but they did provide information as to where officer #6 was now working.

On 08/29/16 at 1:10 p.m. in the ED Education Room, an attempt was made to reach patient #2 by telephone. A voicemail with return call information was left for the patient.

During a telephone interview with RN #2 on 08/29/16 at 1:35 p.m. in the ED Education Room, the RN indicated he/she was working on 04/17/16 when the patient presented to the ED via EMS and escorted by a police officer (#6). The RN explained that after the patient (#2) was triaged the patient was assigned to room D03A in Pod D. The nurse explained that Pod D is a five-bed, locked and monitored area of the ED, designated for patients presenting with psychiatric related complaints. The RN stated that the patient was screened for suicidal ideations and that the patient had denied any suicidal thoughts. The RN continued by stating a few minutes after the patient arrived, the patient indicated he/she had changed his/her mind about being treated and expressed that he/she wanted to leave. The RN stated the patient then ran through the nurse ' s station and exited through the door leading out of the nurse ' s station to the ambulance bay hallway. The RN indicated that he/she did not see the patient exit the building, but had assumed the patient ran outside. The RN stated the police officer (#6) that had accompanied the patient to the ED brought the patient back into the ED. The RN indicated that he/she asked the officer (#6) if the patient was a 1013 and was told by the officer (#6) that the patient was not. The RN stated that since the patient was not a '1013', the patient was able to leave at any time. When asked if the nurse had assessed or noticed any marks on the patient ' s wrists, the RN stated he/she did notice some scratches but that the patient had denied any self-harm. When asked what the RN would have done if the patient had indicated any suicidal ideations and requested to leave the facility, the RN stated he/she would have notified the physician to see if a '1013' were necessary. The RN added that a patient could not be made a '1013' if the patient was not displaying any signs or symptoms of possible harm to themselves or others. The RN stated the patient then LWBS. When asked how the staff was required to handle a patient that wanted to leave AMA or LWBS, the nurse explained that the facility's Leaving the Hospital form was to be completed. The RN went on to explain that when a patient refused to sign the form the nurse and a second witness was to sign the form and indicate on the form and in the medical record that the patient refused to sign. When asked why the form was not filled out, the RN indicated he/she did not know. The RN stated when he/she reported for work the next day, he/she was told by other staff members that the security officer had taken the patient to the McDonald ' s up the street. The RN stated he/she had no idea why the security officer would have done that as the facility has non-emergent transport available for patients. The RN added that the security officer did not have the authority to transport the patient anywhere.

Review of the ED staffing for 04/17/16 during the hours that the patient presented to the ED revealed there was one (1) Registered Nurse and one (1) Psych Technician assigned to Pod D from 04/16/16 at 7:00 p.m. until 04/17/16 at 7:00 a.m. The Pod D census from 4:00 a.m. until 8:00 a.m. was one (1) patient.

On 08/29/16 at 3:00 p.m. in the ED Education Room, the Clinical Compliance Officer (CCO) informed the surveyors that the EMS had refused their request to interview the ambulance attendants who had brought the patient into the ED on 04/17/16 and that the surveyors would have to go through the EMS legal department in order to interview the ambulance attendants. The surveyors requested that the facility try going through the EMS legal department to see if an interview could be conducted with the ambulance attendants.

On 08/29/16 at 3:40 p.m. in the ED Education Room, an attempt to reach the police officer (#6) by telephone at his/her current employer was made. A voicemail with the return call information was left for the on-call sergeant at the department, but the on-call sergeant and/or officer #6 never returned the call.

On 08/29/16 at 4:10 p.m. in the ED Education Room, an attempt was made to reach the patient (#2) by telephone. A voicemail with return call information was left for the patient. Patient #2 never returned any of the calls made by the surveyors.

During an interview #8 with the Chief of Security (COS) on 08/29/16 at 4:45 p.m. in the ED Education Room, the COS confirmed that on 04/18/16 that he/she was notified by the Security Services Manager at a nearby hospital of a possible EMTALA violation. The COS explained that he/she was informed of the event and was also shown a video by the nearby hospital's Security Services Manager which depicted the Memorial security guard (#5) dropping the patient (#2) off at a local fast food restaurant ' s parking lot, which was directly adjacent to the nearby hospital ' s ED. The COS explained that the Security Officer (#5) was questioned and that the Security Officer had initially denied the allegation. The COS provided a copy of the Performance Corrective Counseling and his/her notes.

The COS notes revealed that he/she had received the call from the nearby hospital's Security Services Manager regarding the possible EMTALA violation on 04/18/16 at approximately 9:00 a.m. The COS noted that he/she was informed that a Memorial Security Officer (#5) had dropped a patient off at a local fast food restaurant that was adjacent to the other hospital's ED and that the other hospital's video showed that the patient had then walked into the other hospital's ED. The COS's notes indicated he/she spoke with the security officer who had confirmed that he/she was familiar with the patient and that he/she and the patient had developed a rapport during the patient ' s previous visits to the facility. The COS noted that the security officer denied that he/she transported the patient on 04/17/16. The COS continued by stating that when the security officer was confronted with the video evidence, the officer acknowledged that he/she had transported the patient to the restaurant parking lot. The COS noted that the officer explained that the patient had presented to the facility ' s ED after cutting his/her wrists, that the patient had become upset during the ED visit, and that the officer was concerned for the patient and had asked the patient if he/she wanted to go to another facility for treatment, and that the patient had stated he/she did want to go to another nearby hospital, so the security officer transported the patient to the local restaurant's parking lot in the hospital's security vehicle.

Review of the facility's policy entitled Patrol Vehicles, policy #SEC2017, effective date 09/01/14, revealed that disciplinary action was required for use of the vehicle off hospital property or for unauthorized personal use.

Review of the Performance Corrective Counseling dated 04/26/16 revealed the Security Officer (#5) had been counseled regarding the event, had denied the event, and had been terminated due to failure to follow facility policy.

Observation of Pod D in the ED on 08/30/16 at 10:10 a.m. revealed the Pod was located on the right side after entering through the ambulance bay, the Pod was accessible through two (2) doors. One (1) door was a single door leading to the Pod D nurse ' s station. The door was noted to be locked from the outside (hallway) and required an employee identification badge for entry. The second door was a double-door, which led directly into the Pod and could only be accessed by electronic entry initiated by the nursing staff working on Pod D. Inside the nurse ' s station was a Dutch door (a door that was divided horizontally in such a fashion that the bottom half may remain shut/locked while the top half remained open, if desired) which was noted to be open at the top. The bottom half of the door was locked and could not be opened from the patient ' s side without reaching over the door to unlock it from the inside. A small window, approximately six (6) inches wide by thirty-six (36) inches in length, was noted on the top portion of the door. Two (2) security guards, one (1) nurse (#9), and one (1) psychiatric technician were observed in the Pod D nurse ' s station at the time of the observation.

During an interview with the Pod D RN (#9) on 08/30/15 at 10:15 a.m. in Pod D nurses' station, the RN stated that the top portion of the Dutch door in the nurses' station was normally kept open unless security was in, or near, the nurses' station. The RN stated that if security was not present, the door remained closed. The RN indicated that when patients are brought in via EMS, an electronic report is generated that includes the EMS assessment. The RN stated that the report would then be signed by the receiving nurse. The RN explained that it was possible for the receiving RN to read the electronic report, but that EMS gave a verbal report of the patient when the receiving nurse assumed the patient's care. The RN continued by stating that if a patient told EMS that they were suicidal, but the patient denied suicidal ideations during the psych screening, further questions were asked to assess the patient ' s mental status. The RN stated that if a patient were requesting to leave and had verbalized, or displayed any signs or symptoms of suicidal ideations, he/she would notify the ED physician immediately so that the patient could be assessed for a possible 1013. The RN explained that the physicians were historically prompt in assessing patients presenting with psych complaints who were threatening to leave without being seen. The RN indicated it was the determination of the MD whether or not a patient was to be made a '1013' after being assessed for stability. The RN explained that if a patient wanted to leave without being seen or AMA but refused to sign the form, the RN indicated the patient form was to be signed by two (2) nurses and the medical record noted.

On 08/30/16 at 2:20 p.m. in the Medical Staff President Room, an attempt was made to reach the patient by telephone. A voicemail with return call information was left for the patient.

During a telephone interview with the Psych Tech (PT) (#3) on 08/30/16 at 8:03 p.m. at the Holiday Inn Hotel, the PT stated he/she was working the morning of 04/17/16 when the patient (#2) came into the facility via EMS and accompanied by a local on-duty police officer (#6.) The PT stated that EMS reported that the patient was consuming alcohol and using drugs while at a friend ' s home. The PT continued by stating that EMS explained that the patient was involved in an argument with his/her friends and the police were called. After arriving, the police found the patient in the woods. EMS stated that the patient stated to the police that he/she wanted to go to the hospital to talk to someone about his/her problems. The PT stated that he/she heard the police officer as he/she told the RN (#2) that the patient did have some superficial scratches on his/her wrist area. The officer added that the patient had been running in the woods and that the scratches did not appear to be fresh wounds. The PT stated that shortly after arrival, the patient verbalized that he/she wanted to leave and asked the officer if he/she could leave. The PT explained that the RN asked the officer if the patient was a '1013' to which the officer stated no. The PT then ran out of the room and through the nurse ' s station. The PT stated that the officer brought the patient back into the ED. The PT indicated the officer was again asked if the patient was a '1013'. The officer stated the patient was free to leave at any time. The PT stated the MD was asked to see the patient at that time. The PT explained that the MD spoke to the patient at the bedside and asked the patient if he/she was feeling suicidal or homicidal. The patient indicated at that time that he/she was not. When asked which MD saw the patient, the PT stated he/she could not remember. The PT stated that the MD told the RN that they were not going to hold the patient, and the patient was free to leave. The PT stated the patient then left the ED. When asked if the top portion of the door at the nurse ' s station was usually left open, the PT indicated that the top of the door was only left open if one patient was in the back at one time. The PT stated that if there is only one staff member in the Pod D area, the door is always kept closed and locked. The PT added that staff has asked the management to change the door as they feel unsafe with the Dutch door.

Review of four (4) personnel files #s 1, 2, 3, and 5, revealed all four (4) staff members attended EMTALA training between 05/27/15 and 08/26/15.

Review of two (2) credential files #s 4 and 7, revealed both physicians had completed EMTALA training between 02/17/15 and 08/14/15.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of medical records and policies and procedures it was determined that the facility failed to provide further medical examination and treatment as required to stabilize the emergency psychiatric condition that was within the capabilities of the staff and facilities available at the hospital for one (1) individual (#2) of twenty (20) sampled patients.


Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Examination (MSE) for patient #2 who presented with an emergency medical condition on 04/17/16

.Findings:


The facility's policy entitled Emergency Medical Screening, Stabilization, Treatment & Transfer, policy #PC1019, last revised 10/2015, effective 04/2016 was reviewed. This policy noted that an individual was considered to be stabilized when the treating physician has determined, with reasonable clinical confidence, that the individual's emergency medical condition has been resolved although the underlying medical condition may persist. The policy also revealed that an individual was considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be
performed as an outpatient, or later as an inpatient, provided the individual has been given a plan for appropriate follow-up care with discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he/she is no longer considered to be a threat to self or to others. The hospital, within reason, shall assist or provide necessary information to discharged individuals to secure the necessary follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital.

The facility failed to ensure that stabilizing treatment was provided for Patient #2 who presented to the ED with complaints of suicidal ideations on 4/17/2016.