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.

GRADY MEMORIAL HOSPITAL 80 JESSE HILL, JR DRIVE SE ATLANTA, GA 30303 Nov. 5, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
2400
Based on reviews of medical records, Peace Officer report, on-call schedules, and the Medical Staff Rules and Regulations, and interviews the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the emergency department including psychiatric services which are routinely available to the emergency department at Grady Memorial Hospital for 1 (#18) of 20 sampled patients. Refer to findings in tag A-2406.


Based on reviews of medical records, on-call schedules and interview Grady Memorial Hospital failed to provide stabilizing treatment as required that was with in the capability of the hospital for one patient (#18) of the twenty (20) sampled who presented to the Emergency Department (ED) in need of psychiatric care. Refer to findings in tag A-2407.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


2406
Based on reviews of medical records, Peace Officer report, on-call schedules, and the Medical Staff Rules and Regulations and interviews the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the emergency department including psychiatric services which are routinely available to the emergency department at Grady Memorial Hospital for 1 (#18) of 20 sampled patients.

Findings include:

The hospital's Medical Staff Rules and Regulations effective February 6, 2012 was reviewed. Review of the section titled "B1 Psychiatric Patient" revealed, " For Protection of the patient and the medical staff, care should be taken to meet the needs for psychiatric patients ' treatment of the potentially suicidal patient. The physician attending such a patient should, whenever indicated, request admission of such patient to the psychiatric ward or a psychiatric consult or both. "

The hospital's Psychiatric on- Call Schedule for October -December 2014 (13-A Call schedule) was reviewed. Review of the On-Call schedule revealed that a psychiatrist was on call on November 2, 2014.

The Peace Officer Report dated 11/2/2014 at 10:30 p.m. was reviewed. The report revealed that on 11/2/2014 at 10:00 p.m. patient#18 was picked up and taken to Grady Memorial Hospital. Further review of the Peace Officer's report revealed in part, " Behavior observed at that time: Suicidal and Homicidal Thoughts and actions was extracted from apartment by SWAT. (SWAT - a squad of law enforcement officers trained to deal with situations of unusual danger). While under my observation the conditions checked were present: Made threats to harm self, made threats to harm others, appeared upset, was combative, Unable refused to speak ...Comments or information from family or others having personal knowledge of Individual (Patient #18). The Patient has PTSD (PTSD-Mental Health condition that's triggered by a terrifying event, either experiencing it or witnessing it) from Military ...Physical restraints utilized during transportation- Handcuffs ...Individual's Physical condition (illness or distress): PTSD. Other Information: Will harm himself and others. Transportation provided by ... Peace Officer City Police Department ...Emergency Certificate (1013). " Further review revealed that Patient #18 was delivered to Grady Memorial Hospital at 2230 (10:30) hrs. on 11/2/2014.

The FORM 1013 (legal authority to hold person for behavioral health assessment due to behavior which might be dangerous to self or others) - CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY &REPORT OF TRANSPORTATION (Mental Health) was reviewed. The 1013 form revealed in part, "This is to certify that I have personally examined Patient #18 on 11/2/2014 at 11:38 p.m., which was within the preceding 48 hours of the signing of this certificate. In my opinion this individual (patient #18) appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND; presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons; OR... At the time of my evaluation, the conditions, checked below were present: The individual appears to be a mentally ill. My opinion based on the following observations: Hx (History) of PTSD; non-compliant with treatment. Pt (patient) #18 had to be "extracted from apartment by SWAT team" due to suicidal/homicidal threats and combative behavior. This Individual: Has committed/expressed recent overt acts/threats towards others. Has committed/expressed recent acts/threats of violence towards self ...For example: Pt has made threats to harm self and others (family police officers). The form 1013 was signed by the LPC #1 on 11/2/2014 at 11:40 p.m.

Medical record review for patient #18 revealed the [AGE] year old patient who was transported to the facility's emergency room by a police officer on 11/2/2014 at 10:30 p.m. with complaints of suicidal ideation (SI) and homicide thoughts related to killing family. Patient #18 was triaged on 11/2/2014 at 10:32 p.m. by a qualified Registered Nurse (RN #2), and assigned a triage (medical assignment of degrees of urgency to illness to decide order of treatment) level 2 (emergent). Review of the assessment revealed patient #18 was awake, cooperative and denied self-injurious thoughts and thoughts of hurting others. Continued review of the record revealed an entry on 11/2/2014 at 10:32 p.m. by RN #4 indicating that patient #18 had no plan, means or motivation to hurt self. Further review of the medical record indicated that laboratory tests to include a " Basic Urine drug screen. " Continued review of the record revealed an entry on 11/2/2014 at 10:32 p.m. by RN #4 indicating that patient #18 had no plan, means or motivation to hurt self.

Continued review revealed that LPC #2 recorded on 11/3/2014 at 1:39 a.m., indicated in part, " Pt. brought in by City's Police dept. (Department). Pt appears to be calm and cooperative. Pt denies SI and HI. .. As per LPC #1. Pt is on a 1013 ...Per Officer, City's Police Department (PD), SWAT, and Homeland Security were called to the scene due to patient #18 endorsing suicidal and homicidal ideation (SI/HI) (towards family and police officers)Reports that there was a standoff at the scene; no guns were found at the home. States that pt is a veteran and has been diagnosed with PTSD. Further documentation by LPC#2 revealed in part, " ED Crisis information Assessment started: reason for Psychiatric Intervention; Psych Evaluation " LPC #1 on 11/3/2014 at 12:40 a.m., recorded that patient #18 had a diagnosis of Suicide and Homicide Ideation and PTSD, who was upset regarding not being able to speak to their child, owes large amount child support, who had an argument with the child's mother. LPC #2 recorded that patient #18 brought to the ED by police, stating " wants to go home". Patient #18 is here for psychiatric evaluation. Patient #18 revealed no evidence of S/I or H/I, that via the telephone with the child's mother no visitation would occur until the child support is paid. Patient #18 requested from the child's mother one last communication with the child and she refused. Patient #18 revealed owing ...in child support with monthly payments .... Patient #18 revealed his current wages and how many hours he worked per week; and that the state of "Name of State " has garnished his/her pay check. The patient he/she does not know what to do about this. The patient denies S/I and H/I; stated that he/she has been diagnoses with PTSD.

Patient denied history and violence towards self or others; alert and oriented to person, place and time; cooperative, normal speech, mood: depressed, irritable, sad; Affect: labile; no hallucinations; memory intact, no delusions; good insight; poor judgment. Meets 1013 criteria. Patient continues to deny suicidal/homicidal ideation. Psychiatrist could visit patient in the ECC (Emergency Care Center staffed twenty four hours with Licensed Social Workers (LCSW) and/or Licensed Professional Counselors (LPC) this area designated in the ED for mental/behavioral health concerns).

Documentation of the History and Physical completed by ED doctor #1 on 11/3/2014 at 3:12 a.m. revealed Patient #18 was brought to the ED via the police, patient states "wants to go home". Patient #18 has a past medical history of PTSD, brought in by police for psychiatric evaluation. Patient reports was having an argument with an ex-significant other when authorities were called in by family. Patient #18 confirmed the use of marijuana use but denies alcohol use. Review of systems, including Psychiatric/Behavioral, were all negative. Medical decision making: Does not have any symptoms. Labs positive for amphetamines (a stimulant, mood altering drug and used to treat attention deficit hyperactivity disorder) but patient denies use, possibly secondary to medicine use, and the patient cannot remember which medications he/she takes. Patient has an outside psychiatrist at Veterans Administration Hospital with whom the patient says he/she will follow up. Does not meet 1013 criteria, is not a current threat to self or others. Diagnosis: Domestic dispute, Condition: stable and Disposition: Discharge: To home.

Review of the medical record from another Acute Care Hospital revealed that patient #18, presented to their Acute Care Hospital ED with the same complaints feeling SI/HI on 11/3/14 (less than 24 hours after being sent home from Grady Memorial Hospital ED). Further review of the record indicated an admission date of [DATE] and transfer date of 11/5/2014 to a psychiatric hospital or Patient #18. The patient told the ED that he had been seen at Grady Memorial Hospital and was discharged . Patient #18 was aggressive, threatening and had to be physically restrained. The Acute Care Hospital transferred patient #18 via a 1013 to a local mental hospital.


Review of a Psychiatric Evaluations dated 11/8/2014 from the Psychiatric Hospital revealed a 1013 admission with delusional thinking and SI was transferred from an Acute Care Hospital with threats of self-harm. Further review documentation revealed that on 11/12/2014 Patient #18's diagnosis were listed as Substance Abuse-induced mood disorder, PTSD, and Cannabis abuse.


Interview on 11/4/2014 at 12:30 p.m. with the ED Clinical Manager and the Patient Safety Specialist revealed that the hospital had 24/7 Licensed Clinical Social Worker/Licensed professional counselor (LCSW/LPC) coverage, and a psychiatrist (with varying duty hours) for behavioral health assessments in the ED. The attending psychiatrist was available to the CS/LPC as needed for consultations. The hospital has one behavioral health unit which admitted both voluntary and involuntary admissions. There was no indication in the medical record that Pt#18 was evaluated by a psychiatrist. Grady Memorial Hospital had a psychiatrist on call on 11/2/2014 when Patient #18 was brought to the hospital by law enforcement seeking a psychiatric evaluation, after being extracted from his home by the City's Police Department and the SWAT Team. The facility failed to have patient #18 evaluated buy a psychiatrist despite having a psychiatrist on call on 11/2/2014 when patient #18 presented seeking psychiatric evaluation.

Interview on 11/5/14 at 5:15 p.m. ED doctor #2 revealed the physician recalling patient #18, and had no knowledge of what happened at the patient's home prior to being brought to the ED. ED doctor #2 revealed during assessment of patient #18, the patient was very calm, conversed normally, denied SI/HI and was safe for discharge to follow up with the VA., which the patient agreed to do. The patient was discharged to home with instructions for follow up, no prescriptions were provided.

The facility failed to ensure that an appropriate medical screening examination was provided related to patient #18's presenting psychiatric signs and symptoms that were observed and documented (1013 ' d by LSC #1 that pt. #18 appeared mentally ill, was a danger to self, family and policemen, and had poor judgment.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, on-call schedules and interview Grady Memorial Hospital failed to provide stabilizing treatment as required that was with in the capability of the hospital for one patient (#18) of the twenty (20) sampled who presented to the Emergency Department (ED) in need of psychiatric care.

Cross reference for details in Tag A-2406

Findings include:
The hospital's Psychiatric on- Call Schedule for October -December 2014 (13-A Call Schedule) was reviewed. Review of the On-Call schedule revealed that a psychiatrist was on call on November 2, 2014.
Review of the medical record from another Acute Care Hospital revealed that patient #18, presented to their Acute Care Hospital ED with the same complaints feeling SI/HI on 11/3/14 (less than 24 hours after being sent home from Grady Memorial Hospital ED). Further review of the record indicated an admission date of [DATE] and transfer date of 11/5/2014 to a psychiatric hospital or Patient #18. The patient told the ED that he had been seen at Grady Memorial Hospital and was discharged . Patient #18 was aggressive, threatening and had to be physically restrained. The Acute Care Hospital transferred patient #18 via a 1013 to a local mental hospital.


Review of a Psychiatric Evaluations dated 11/8/2014 from the Psychiatric Hospital revealed a 1013 admission with delusional thinking and SI was transferred from an Acute Care Hospital with threats of self-harm. Further review documentation revealed that on 11/12/2014 Patient #18's diagnosis were listed as Substance Abuse-induced mood disorder, PTSD, and Cannabis abuse.


Interview on 11/4/2014 at 12:30 p.m. with the Emergency Department (ED) Clinical Manager and the Patient Safety Specialist revealed that the hospital had 24/7 Licensed Clinical Social Worker/Licensed professional counselor (LCSW/LPC) coverage, and a psychiatrist (with varying duty hours) for behavioral health assessments in the ED. The attending psychiatrist was available to the CS/LPC as needed for consultations. The hospital has one behavioral health unit which admitted both voluntary and involuntary admissions.

The facility failed to ensure that stabilizing treatment was provided to patient #18 on 11/2/2014 as evidenced by failing to have the on call psychiatrist (capability) provide further psychiatric examination and treatment for patient #18.