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.

IOWA LUTHERAN HOSPITAL 700 EAST UNIVERSITY AVENUE DES MOINES, IA 50316 July 1, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of hospital documents, policies, medical records, and staff interviews, the hospital failed to ensure to enforce its EMTALA policy to ensure staff provided an appropriate medical screening examination for 3 of 25 sampled patients who presented to the Emergency Department (ED) of the hospital on May 9, 2015, May 19, 2015, and June 15, 2015. (Patient #6, #18 and Patient #25.)

Failure to ensure the ED staff provided an appropriate medical screening examination for each of the patients requesting emergency medical care in the ED in accordance with the hospital's EMTALA policy could potentially result in patient harm and/or poor outcomes for patients.

Findings include:

Review of the hospital policy titled "Transfer and Emergency Examination- EMTALA," undated, revealed in part " ...Medical/Psychiatric. A medical condition manifesting itself by acute symptoms or sufficient severity, (including... psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Serious impairment to bodily functions...or Serious dysfunction of any body organ or part...Stable for discharge...A patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonable performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions...."

Refer to A 2406 for additional information concerning the medical screening examination of Patient #6, #18, and Patient #25.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of hospital documents, polices, medical records, and staff interviews, the hospital failed to ensure Patient #6, #18, and Patient #25 received an appropriate medical screening examination. The investigation involved review of the Emergency Department (ED) medical records for 25 sampled patients who presented to the ED for an emergency medical condition from March 28, 2015 to June 15, 2015.

Failure to ensure Patient #6, #18, and Patient #25 received an appropriate medical emergency examination could potentially result in patient harm and/or poor patient outcomes.

Findings Include:

Review of the hospital policy titled, "Inpatient Psychiatric Admission Criteria" dated 7/2015, included in part "...Purpose The inpatient psych admission criteria listed below facilitate the appropriate hospitalization of people with mental health conditions...The clinical judgement of psychiatrists, ED physicians/providers and members of Access Center is vital in determining the disposition of a patient referred for evaluation...Behavioral Health-Psychiatry Strong consideration for hospitalization should occur when the clinical findings identify immediate safety risks (in the last 48 hours) Examples include...Command hallucinations with direction to harm self/others...Suicidal ideation... Elevated/Expansive Irritable mood and potential to harm self/others...Psychotic symptoms and potential to harm self/others...Appropriately obtained collateral information should be considered in making the decision to admit a patient. Examples include...Report from any family, guardian and friends present, Report from any sending facility...Ultimately if a patient does not meet criteria for hospitalization the patient should be educated as to why this decision and also be given options for outpatient care..."

1. Review of Patient #6's closed medical record showed on 6/15/15 at 8:00 PM, the patient presented to the ED with the complaint of suicidal thoughts and reported he ran away from home.

a. The medical record did not contain evidence the Access Staff and/or Social Worker EE followed the hospital policies to provide an appropriate medical screening examination for Patient #6 without contacting the on call psychiatrist regarding Patient #6's suicidal thoughts, running away from his "host home", labile mood, fearful to angry to silly responses, memory impairment, diminished judgement, disheveled appearance, and restlessness prior to Patient #6's discharge to home.

b. At 8:08 PM Physician Assistant (PA) DD's documentation included in part, "...the patient 'ran away from home' had suicide thoughts. He reportedly making suicidal threats today. Patient is cleared for Access Center evaluation. Patient will be discharged home..."

c. Review of the ED note showed a medication history of Seroquel (Bipolar) Cogentin (Restlessness), Thorazine (agitation), and Depakote.

d. ED note titled, "Behavioral Health Initial Assessment" At 11:42 PM Social Worker EE documentation included in part, "...Patient came to ER reporting suicidal thoughts and the patient ran away from his "host home" Patient had been inpatient at another hospital in the past. Patient promised to be safe and return home..."

e. Social Worker EE documentation included the following:

Risk Factors:
Intellectual Impaired...Not satisfied with placement...legal problems for aggression
Mood: Labile (unstable mood), fearful to angry to silly...Some memory impairment, diminished judgement and insight
Appearance: disheveled
Motor: Restlessness
Recommendations: Consult with PA...Host contacted and came to retrieve patient. Guardian called and informed of patient's discharge to home

f. ED note titled, "Discharge Planning" at 9:35 PM Social Worker EE documentation included in part, "...You have made a promise to be safe and return to your house. Please follow up with your psychiatric provider and tell them of your visit here..."

g. During an interview on 6/30/15 at 10:00 AM, ED Registered Nurse (RN) B stated, "(Patient #6) came in for a psychiatric evaluation. He had complaints of suicidal thoughts." RN B reported she triaged the patient. RN B reported the Access Center is specialized in mental health with RN's and social workers. Once the patients are medically cleared the Access Center staff evaluate the patients and talked to the psychiatrist to determine inpatient vs. outpatient treatments. RN B stated, "The nurse goes over the medical history, medication history, and complete the physical assessment. Labs are determined by the provider or the psychiatrist if they are completed or not." RN B stated, "(Patient #6) was brought to the ED by a business owner. He had suicidal thoughts. During the triage he did voice he had suicidal thoughts. He did not have a plan when asked." RN B reported the suicide risk screen is filled out on a case by case basis. RN B stated, "If the patient is being seen by the Access Center, the nurse does not do this. The Access Center screens patients for the mental health."

h. During an interview on 6/30/15 at 12:15 PM, ED Physician Assistant (PA) DD stated, "My assessment the patient said he just wanted to run away from home. He did not want to be there any more. Patient told triage nurse and told others he wanted to commit suicide. When I questioned him, he denied any suicidal thoughts." ED PA DD reported she referred the patient to the Access Center for evaluation because he made a threat to the triage nurse about telling others he wanted to commit suicide. ED PA DD stated, "Access Center does call psychiatrist for direction about to admit or outpatient. I don't personally talk to the psychiatrist." ED PA DD reported if there are no physical complaints or medications she doesn't usually order laboratory tests. ED PA DD stated, "If psychiatrists requests labs it would be for medical clearance if admitted . ED PA DD reported she was not present when Patient #6 was discharged home.

i. Review of a document titled, "Arrest Report" dated 6/15/15 stated in part, "...(Patient #6) used his hand as a gun to rob a clerk at a local store..." This incident occurred approximately 2 hours after Social Worker EE, without consulting the on-call psychiatrist, discharged Patient #6 with a promise to be safe and return to the patient's home.

2. Review of Patient #18's closed medical record showed on 5/9/15 at 1:07 PM, the patient presented to the ED with the complaint of suicidal thoughts and alcohol intoxication.

a. The medical record did not contain evidence the Access Center staff followed the hospital policies to provide an appropriate medical screening examination for Patient #18 without performing a Behavioral Health Initial Assessment or contacting the on-call psychiatrist regarding Patient #18's suicidal ideation, suicidal threats and intent, alcohol intoxication, agitation, irritability, and verbally abusive behavior. Emergency Physician AA told staff if Patient #18 wanted to leave let him leave. (Refer to Document titled, "Incident Report" dated 5/9/15 at 2:02 PM).

b. At 2:29 PM Emergency Physician AA's documentation included in part, "...Patient drinks everyday...his sister came over to check on him and he told her he just wanted to be with his dad who is deceased ...Patient will not elaborate on any particular suicide plan...presenting symptoms...agitation, depression, suicidal thoughts, and suicidal threats...Associated symptoms...irritability and poor judgement...Risk factors...history of depression and
alcoholism..."

c. Emergency Physician AA's documentation included the following:

Review of Symptoms: Positive for irritability
Psychiatric/Behavioral: Positive for suicidal ideas and agitation
Physical Exam: Slurred Speech and smell of alcohol
Imaging/Studies reviewed: The patient was evaluated by Access Center personnel. I feel he is not a danger to hurt himself and the Access Center also felt he was not in danger. He eventually contracted for safety and he'll be discharged .

d. ED note titled, "Patient Care Timeline" showed ED RN H documented included the following in part:

"...At 1:29 PM Patient states,"as soon as i walk out of here im going to kill myself" States wants to go be with father who is deceased .

At 1:43 PM Security called for standby.

At 2:01 PM Psychosocial - Irritable...aggressive verbally...mild confusion...Intent and plan for self injurious actions (Will not state plan but states "if you let me leave here I will kill myself")

e. At 1:44 PM ED Physician AA's documentation included in part, "... Provider at Bedside- Provider in: Provider In..."

f. Review of a hospital document titled, "Incident Report" dated 5/9/2015 at 2:02 PM included in part, "...Incident type...Standby...Offender (Patient #18)...incident occurred on 5/9/15 at 1:35 PM Emergency Department Access Center...called for a standby for Room B. The patient...(Patient #18) was wanting to leave AMA (Against Medical Advice)...(ED Physician AA) spoke with patient and informed staff if the patient wanted to leave AMA to let him. Staff then released me from standby....Incident... End Date 5/9/ 2015 at 1:55 PM..."

g. At 2:10 PM Access Nurse RN G's documentation titled, "Progress Note" included in part, "Patient brought to Access Center after telling police he was going to kill himself. He then wanted to go to jail instead of Access Center, sister was here and wanted to leave. Became agitated with sister in room. Did not want to stay, did not voice any suicidal statements, and left to have cigarette. No charges were given by police; patient's sister left shortly after patient did..."

h. ED PA AA's Note titled, "ED Disposition" documentation included in part, "...Discharge (Patient #18) discharge to home/self care...Condition at discharge: Stable..." Security was released from standby at Patient #18's room 20 minutes before the patient went outside to have a cigarette.

i. At 2:15 PM RN A documented Patient #18 was discharged .

j. During an interview on 7/1/15 at 8:05 AM ED Physician AA stated, "I remember him. He was not going to commit suicide. He was no danger to himself. No labs were drawn because if no physical complaints, no withdrawals, or intoxication, not necessary to do." ED Physician AA reported she referred him to the Access Center for a psych evaluation and Patient #18 refused the Access Center and went out for a cigarette. ED Physician AA stated, "Once I determined he was not suicidal the Access Center is to determine the mental health condition. I should have told staff not to let the patient leave until the psych evaluation. He should of been kept at the hospital until the psych evaluation. We can physically keep patients here until determined safe after a suicidal threat."


3. Review of Patient #25's closed medical record showed on 5/19/15 at 9:41 PM, the patient presented to the ED with the complaint of hallucinations (auditory) and suicidal thoughts.

a. The medical record did not contain evidence the Access Center staff and/or the on-call psychiatrist followed the hospital policies to provide an appropriate medical screening examination for Patient #25. The on-call psychiatrist was called but did not see Patient #25 who expressed suicidal ideations multiple times during ED visit along with increased prevalence of hearing voices telling her to hurt herself.

b. On 5/20/15 at 1:32 AM ED Physician Assistant CC documented included in part, "...(Patient #25) presented to the ED with complaints of "suicidal thoughts." and auditory hallucinations and hearing voices...with a plan to cut her wrists..."

c. ED PA CC's documentation included the following:

History Chief Complaint: Suicidal
Presenting Symptoms: hallucinations (auditory) and suicidal thoughts
Degree of incapacity (severity): Mild
Onset quality: Sudden
Duration: 1 day
Progression: Worsening
Relieved by: Nothing
Exacerbated: Hearing voices
Risk factors: history of mental illness and history of suicide attempts
Psychiatric/Behavioral: Positive for suicidal ideas and hallucinations (auditory)

Physical Exam:
Psychiatric: She expresses suicidal ideation...She expresses suicidal plans...
Patient has a plan of suicide but no intent to commit suicide.

ED Course
Suicidal thoughts
Patients course in the emergency department consisted of:
I have consulted with access center staff, who will also assess the patient and staff it with their attending on-call psychiatrist
Patient can contract for safety
Access Center will discharge patient

Assessment
Suicidal thoughts

d. At 9:41 PM ED RN B documented Patient #25 was in pain at that time (unknown what type of pain and/or where was the patient's pain)

e. At 10:22 PM ED RN H documented Patient #25 had pain at a level 5 out 10. (10 being the worst pain)

f. ED note titled, "Behavioral Health Initial Assessment" on 5/20/15 at 2:20 AM Access Nurse RN E documentation included in part, "...Presenting Problems and Stressors...Suicidal ideation, Psychosis...has multiple stressors...has chronic issues with hearing voices...This afternoon the voices were increasingly tell her to harm herself...When asked how she would harm herself, she was uncertain except maybe cut herself...She had told staff she "didn't feel safe" and they brought her here...Talked with (Psychiatrist BB) who agrees for discharge back to the group home...

g. Access Nurse RN E's documentation included the following:

Risk Factors:
Suicidal Ideation: Is having increased thoughts of suicide. States unspecified plan, but contemplating cutting herself.
Suicide Plan: above
Previous Self Harm: yes
Previous Suicidal Plans: yes
Previous Suicidal Behavior: yes
Plan for Safety in Hospital: Admission: States she feels better in the hospital
Affect: Blunted
Mood: Depressed
Medications: No current facility-administrated medications for this encounter

h. During an interview on 6/30/15 at 8:40 AM, the Executive Director of Behavioral Health reported the Access Center evaluations are competed by a group of staff specifically working in the ED. They are nurses, therapists, and social workers that are trained specifically for mental health. The Executive Director of Behavioral Health stated, "If a patient presents with mental health symptoms, the provider will ask the Access Center to evaluate the patient for mental health concerns. Generally, these patients did not have physical conditions, but have mental health conditions only," The Executive Director of Behavioral Health reported the Access Center staff completes the mental health assessment to determine if the patient requires inpatient or outpatient treatment. The Executive Director of Behavioral Health stated, "The Access Center staff assess and collect the information and call the on-call psychiatrist with this information to determine if the patient is requiring admission." The Executive Director of Behavioral Health reported the psychiatrist would make the decision for the patient to be admitted .

i. During an interview on 6/30/15 at 4:00 PM, Access Center RN E stated, "We evaluate all mental health patients presenting to ED including for chemical dependency." RN E stated, "The triage nurse brought her (Patient #25) to the Access Center. She presented with suicidal ideation and psychosis. She had (group home) staff bring her to the ED. She did not feel safe and was actively suicidal with a plan to cut herself." RN E reported the staff tried to contact her psychiatrist but did not have success. RN E stated, "I talked to (Psychiatrist BB) about the patient symptoms. He decided she could go back to the group home with 24 hour supervision." RN E stated, "I identified (Patient #25) was on 5 different psychiatric medications. I would do labs if patient was on librium or tegretol. I have seen this patient before. Evenings when alone...She gets more anxious."

j. During an interview on 7/1/15 at 8:20 AM, Psychiatrist BB reported (Patient #25) lived in a 24 hour 7 days a week staffed community based living center. He reported Patient #25 was a chronic mentally ill patient. Psychiatrist BB stated, "The staff relayed the information over the phone the patient was hearing voices, having hallucinations, stating she was going to commit suicide by cutting herself. She told the staff she didn't feel safe so they brought her to the ED." Psychiatrist BB reported he was on call. Psychiatrist BB stated, "I discharged her back to the group home because her changing state in the ED. Came in with crisis, suicidal ideation, assessed in ED for crisis intervention. I was told hearing voices was chronic for her. While in the ED was able to process information, calmed down, and the (group home staff) felt safe taking patient home." Psychiatrist BB reported the patient says statements in crisis and after evaluation she settled down and was no longer a harm to self. Psychiatrist BB stated, "Nothing in this visit showing a metabolic concern. Provider assessing negative for physical exam nothing determined a need for labs to rule out metabolic." Psychiatrist BB reported if the patient would of showed symptoms, had tremors and so forth he would do labs. Psychiatrist BB stated, "Discharge appropriate, safe to go back to supervised home." Psychiatrist BB reported he did not come to the ED to see Patient #25.

k. During an interview on 7/1/15 at 8:45 AM, ED PA CC reported Patient #25's complaints were suicidal thoughts and she was going to cut her wrists and auditory voices telling her to do it. ED PA CC stated, "She said she had no desire to commit suicide and was scared of what the voices were saying." ED PA CC reported Patient #25 had no physical concerns only psychiatric. ED PA CC stated, "I evaluated her for safety. Once she was safe in the ED I had Access Center evaluate her for psychiatric concerns." ED PA CC reported Patient #25 lived where there was 24 hour 7 days a week care. ED PA CC stated, "Contracted for safety. Staff removed the dangerous items. I agreed with assessment by the Access Center the patient was safe to discharge to group home."