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UNITYPOINT HEALTH-MARSHALLTOWN 3 S 4TH AVE MARSHALLTOWN, IA 50158 June 2, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of policy/procedures, review of medical record documentation, and staff interviews, the hospital failed to enforce policies/procedures requiring staff to provide an appropriate medical screening exam sufficient to determine whether an emergency medical condition (EMC) existed for 1 (Patient # 3) of 25 patients who presented to the hospital's Emergency Department (ED) requesting care between 12/1/13 through 5/28/14. Patient #3 returned to the hospital by ambulance the following day after a suicide attempt and was transferred to another hospital for further stabilizing treatment.

Failure to provide an appropriate medical screening exam in the ED for patients requesting care could result in staff providing inadequate or ineffective care to stabilize an EMC and result in the patient's condition worsening.

Findings include:

1. Review of the hospital policy/procedure titled "Transfer and Emergency Examination Policy," reviewed 8/2011, revealed in part... "2. Definition of Emergency Medical Condition (EMC). a. Medical/Psychiatric is 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: ii. Serious impairment to bodily functions.

Definition of a MSE. 6. An MSE is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an EMC exists. The MSE must be provided by Qualified Medical Personnel, as defined by Administrative Policy and Procedure No. 141, entitled "Medical Screening Exam Providers"."

2. Review of the hospital's Policy Number: P-3 Physician Coverage, last revised 8/2012 showed at bullet 5). Patients with life threatening illness or injuries will be assessed immediately by the EDP (ED Physician). Under "Psychiatry and Mental Health Call", the policy stated at bullet 1). The psychiatrist and/or mental health staff will provide consultation for the ED on a rotating basis as determined by their office. The "Psychiatry Call" physician and/or [name of clinic] staff will be available for/or to assist with the management of the patient with an acute psychiatric problem when requested by the EDP."

3. Review of Staff D's (Psychologist) "Allied Health Professional - Psychologist Request For Duties" dated 10/5/12 showed that "Mental health consultations and evaluations (provided) on request by physician."

4. Review of Patient #3's ER medical record dated 5/14/14 at 9:42 AM revealed the following documentation.

Patient #3 presented on Wednesday 5/14/14 at 9:42 AM accompanied by a co-worker complaining of dizziness that started the day before. The ED nurse documented the patient had a hard time following commands. Constantly repeats self. Abnormal verbal response, expressive aphasia (trouble speaking). At 2:00 PM staff administered Geodon 10mg (milligrams) IM (intramuscularly) (antipsychotic medication for manic behavior). At 2:11 PM patient was discharged home with spouse.

Physician Assistant A evaluated Patient #3 at 10:16 AM and documented review of the patient's history was limited by psychosis. Chief complaint - changed mental status. The patient has been confused and had trouble concentrating. This started yesterday, is still present, worsening and patient was last witnessed to be well 2 days ago. Patient's spouse reports the patient feels someone is out to get him. The spouse reports the patient had similar symptoms in the past and required hospitalization . The patient had not been on psychiatric medications for years until last week when started on Wellbutrin (antidepressant) for depressive symptoms. Patient has a past history of major depression with psychosis. Patient appears to have auditory hallucinations. Patient does not understand illness or feel treatment is necessary. Consult obtained from mental health [psychologist] and will see patient in the ED. Patient disposition per consultant. Clinical impression - acute psychosis with paranoia.

Staff D (Licensed Psychologist) evaluated Patient #3 on 5/14 at 11:50 AM and documented patient was brought to the ED by his employer because he was having trouble with decision making at work. Today the patient's behavior in the ED is somewhat suspect. The patient wandered around before the spouse arrived and seemed to have difficulty understanding what was going on when the physician's assistant talked with him. Further documentation showed during the examination, patient # 3 admitted that "he is not thinking straight and he is not exactly sure what is going on and his wife can better articulate the problem than the patient." Under "Psychiatric History" Staff D documented "I did not take a full history; however, he has a diagnosis of bipolar II with the most recent episode being hypomanic and alcohol use." Further documentation showed that Staff D contacted Staff C, Psychiatric Nurse Practitioner (NP) at the [clinic] who suggested some medications to Physician Assistant A.

The medical record did not contain evidence that patient # 3 received a medical screening examination sufficient to determine whether an emergency medical condition existed. The ED Physician on duty did not examine patient # 3 who was displaying psychotic symptoms after recently beginning treatment with Wellbutrin for depression. Physician Assistant A ordered administration of an antipsychotic medication (Geodon) based on the recommendation provided by the clinic ARNP who did not come to the ED to examine patient # 3. Physician Assistant A provided orders for discharge 11 minutes after patient # 3 received a shot of Geodon without a re-evalation. Refer to tag A2406 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of policy/procedures, medical records, and interview with staff, the hospital failed to provide an appropriate medical screening exam for 1 of 25 patients (patient # 3) who presented to the hospital's Emergency Department (ED) requesting care between 12/1/13 through 5/28/14. Patient #3 returned to the hospital by ambulance the following day after attempting suicide and was transferred to another hospital for stabilizing treatment.

Failure to provide an appropriate medical screening exam for patients that present to the ED requesting care could result in staff providing inadequate or ineffective care to treat an emergency medical condition (EMC) and result in the patient's condition worsening.

Findings include:

1. Review of Patient #3's ED medical record dated 5/14/14 at 9:42 AM revealed the following documentation.

Patient #3 presented on Wednesday 5/14/14 at 9:42 AM accompanied by a co-worker complaining of dizziness that started the day before. The ED nurse documented the patient had a head concussion 3 years ago and "feels the same way today as he did with the head concussion." Further documentation revealed patient # 3 had a hard time following commands, constantly repeated himself and had expressive aphasia (trouble speaking).

Physician's Assistant A examined Patient #3 at 10:16 AM and documented the patient had been confused and had trouble concentrating for the past two days. Further documentation indicated patient # 3's wife stated he told her that he felt like someone was out to get him. She reported he's had similar problems in the past and required hospitalization . Physician Assistant A documented that the patient had not been on any psychiatric medication until last week when he was started on Wellbutrin (anti-depressant). Further documentation specified patient # 3 had a past history of major depression with psychosis (loss of contact with reality). Physician Assistant A documented that patient # 3 was confused, slow to respond, and provided inaccurate answers to questions and inconsistent responses to commands. Further documentation specified patient # 3 had a flat affect, appeared to have auditory hallucinations, and did not appear to understand his illness or feel treatment was necessary.

Physician's Assistant A contacted Staff D (a master's prepared licensed psychologist) who came to the ED and evaluated Patient #3 on 5/14/14 at 11:50 AM. Staff D documented patient # 3's "behavior in the emergency room is somewhat suspect." "He was wandering around before his wife came and he seemed to have some difficulty understanding what was going on when the physician's assistant talked to him." Under "Psychiatric History" Staff D documented, "I did not take a full history; however, he has had several manic-like breaks and at [name of clinic] where he has been a patient he has a diagnosis of bipolar II (periods of depression last longer than periods of hypomania)." Further documentation showed that patient # 3 had prior psychiatric inpatient hospitalization s. Under "Recommendations", Staff D documented that an advanced practice registered nurse (ARNP) at [name of clinic] spoke with Physician Assistant A and recommended a medication to calm patient # 3. Further documentation specified that patient # 3 should take off work and return to [name of clinic] next week, and return to the ED and/or [name of clinic] "should matters worsen."

At 2:00 PM the ED nurse administered Geodon 10mg (milligrams) IM (intramuscularly) (antipsychotic medication). At 2:11 PM patient # 3 was discharged home with his spouse. Physician Assistant A documented under "Clinical Impression" that patient # 3 had "Acute psychosis with paranoia (Bipolar)."

The medical record did not contain evidence that patient # 3 received a medical screening examination sufficient to determine whether an emergency medical condition existed. The ED Physician on duty did not examine patient # 3 who was displaying psychotic symptoms after recently beginning treatment with Wellbutrin for depression. Physician Assistant A ordered administration of an antipsychotic medication (Geodon) based on the recommendation provided by the clinic ARNP who did not come to the ED to examine patient # 3. Physician Assistant A provided orders for discharge 11 minutes after patient # 3 received a shot of Geodon without re-evaluation.

Review of a second medical record showed patient # 3 presented to the ED by ambulance about 24 hours after discharge on 5/15/14 at 2:23 PM. Documentation showed the trauma team responded to the ED to provide critical emergency care to patient # 3 who had attempted suicide by cutting his neck with a skill saw. At 2:35 PM blood was rapidly administered along with other intravenous fluids and medications. At 3:01 PM patient # 3 was transported by an air ambulance to another hospital with a higher level of care and the capabilities to provide further treatment to stabilize his emergency medical condition.


2. During an interview on 5/28/14 at 1:50 PM, Physician Assistant A, stated that Patient #3 entered the ED on 5/14/2014 accompanied by his boss. The patient complained of hearing voices (auditory hallucinations), but they were not telling him to harm self. Physician Assistant A stated he called the patient's spouse in and asked about the patient's behavior. The spouse reported the patient was a little paranoid that morning, but nothing prior to that. The patient was seen by his family physician the week before and was started on Wellbutrin. The evaluation showed the patient had auditory hallucinations, but denied suicidal ideation. Physician Assistant A stated he thought the patient required hospitalization at that time because of the psychosis. Physician Assistant A stated he felt comfortable with discharging the patient after the psychiatric consult.

3. During an interview on 5/28/14 at 3:30 PM, Staff D, Psychologist, stated Physician Assistant A asked for a psychiatric consult on 5/14/2014 because Patient #3 acted unusual and thought the patient might need an inpatient admission for the unusual behavior. Staff D said he completed a safety assessment and the patient denied any thoughts of harm to self or others. The patient had no auditory hallucinations during the consultation. The spouse denied the patient was suicidal. Staff D stated he was aware the patient attempted suicide with similar symptoms in the past and required inpatient treatment. Staff D said he discussed this with the patient's spouse and the spouse agreed to the discharge.

During further interview on 6/2/14 at 11:00 AM, Staff D stated Patient #3 had been transferred to another hospital in January 2012 for inpatient psychiatric care following ingestion of a degreaser, and that the patient exhibited similar behaviors at that time as the patient exhibited on 5/14/14.

4. During an interview on 6/2/14 at 10:15 AM, Patient #3's spouse stated the psychologist evaluated her husband and stated he was ok. The spouse said her husband had past suicide attempts and that the psychologist had seen him after his hospitalization . The spouse stated that things got worse for her husband on 5/14/14 after being on Wellbutrin for a week. She stated her husband thought he was under surveillance and was pacing in the ED. The spouse stated her husband did not hear things until after starting on the Wellbutrin. The spouse stated she did not refuse to have the patient admitted for inpatient care.

5. During an interview on 7/7/14 at 9:45 AM, ED physician B acknowledged she did not examine Patient #3 on 5/14/14 during the patient's ED visit. Physician B stated she reviewed Patient #3's ED record on 5/14/14 after the patient had been discharged .

6. During an additional interview on 7/7/14 at 10:10 AM, Physician Assistant A stated he was not aware Patient #3 had attempted suicide prior to 5/14/14. Physician Assistant A acknowledged he did not consult with Physician B, the on duty ED physician, prior to discharging the patient on 5/14/14.

7. Review of a third medical record revealed Patient #3 (MDS) dated [DATE] after he jumped down 3 to 4 stairs at home intentionally hitting his head on a concrete floor due to feeling depressed and trying to hurt himself. The patient sustained a laceration on the top of his head. The patient later recanted and stated that he did not want to hurt himself. Physician Assistant A examined patient # 3 and obtained a mental health consultation by a Licensed Independent Social Worker from [name of clinic]. Physician Assistant A documented he was concerned that the patient had a high risk of injuring himself even though the patient recanted. Physician Assistant A provided orders for discharge and documented under " Assessment " 1). Depression, 2). Scalp laceration after self-inflicting a wound by jumping off stairs but denying suicidal ideation. Physician Assistant A provided orders for patient # 3's discharge.

8. Review of a fourth medical record revealed Patient #3 returned to the ED after attempting suicide by ingesting a degreaser about 48 hours after discharge on 1/5/2012. During the 1/5/2012 ED visit the patient admitted to feeling suicidal for 3 to 5 days. The patient was then transferred to another hospital for psychiatric inpatient care to stabilize his emergency medical condition.