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CARROLL HOSPITAL CENTER 200 MEMORIAL AVENUE WESTMINSTER, MD 21157 Dec. 22, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of the medical record for patient #1, review of hospital policies and procedures and staff interviews it was determined that the staff failed to provide and document continued care needs for patient #1 in regard to psychiatric management. As a result there was a delay in treatment of the patient's diagnosed psychiatric condition and symptoms.

Patient #1 presented to the Emergency Department (ED) on 12/5/2015 with altered mental status and was reporting hallucinations and voices telling her to harm herself. The patient was subsequently admitted INVOLUNTARILY to the Behavioral Health Unit (BHU) at 8:55 AM as being a danger to self. The History and Physical exam by the psychiatrist was noted as being completed more than 24 hours after admission to the BHU (dictated on 12/6/2015 at 6:25 PM). On 12/6/2015 at approximately 2:11 PM the patient sustained an unwitnessed fall in the Behavioral Health Unit. An interview with the Patient Safety Officer (who investigates falls) on 12/22/15 revealed that "Staff heard a commotion in the patient's room. Staff then went to the patient's room and found the patient on the floor with a little blood on her right eyebrow." A COT (emergency response team) was called and immediately responded. According to the patient's medical record, the patient was transferred to the Critical Care Unit (CCU) for close observation because the patient could not remember the events prior to, during, or after the fall. The patient's vital signs remained stable, and other than the patient having an abrasion to her right eyebrow and a nose bleed, no other injuries were noted on the critical care physician's assessment.
The patient was monitored in CCU from 12/6/2015 until medically cleared and discharged from CCU on 12/7/15 at 5:03 PM. The discharge summary written on 12/7/15 by the CCU provider stated in part, "Patient was observed overnight and had no signs of severe traumatic brain injury. She did have hallucinations and stated that the voices were telling her to harm herself. She was accepted for readmission to 4 West for continued psychiatric treatment." The patient was to be discharged from CCU to the inpatient BHU (4 West). An interview with the patient safety officer on 12/22/2015 revealed that, at the time, no beds were available in the BHU. So the patient was transferred from CCU to 3 West, a medical/surgical unit on 12/7/2015 to await an open bed in the BHU.

The patient stayed in the medical/surgical unit waiting for a BHU bed to become available from 12/7/2015 to 12/11/2015. On 12/11/2015 the patient was transferred to the BHU. During the 4 days in which the patient was awaiting transfer to the BHU, the psychiatry staff failed to document daily psychiatric assessments and rounding discussions, treatments, therapies and progress notes. A psychiatric consultation was completed by provider #1 (psychiatrist) on 12/7/2015 and indicated that the patient continued to exhibit psychiatric behaviors that warranted admission and return of the patient to the psychiatric unit. The plan noted by provider #1 on this consultation was to "return to inpatient psychiatric hospitalization , the patient has been cleared (medically), and the patient may resume current medication as prescribed from inpatient service." Prior to her fall on 12/5/15 and transfer to CCU the patient had been ordered Haldol 5 mg twice per day and Ativan 1 mg twice per day to treat her psychiatric condition, the initial reason for her admission. No medications to treat psychiatric behaviors/illness were resumed for this patient until a bed was available in the BHU and the patient was transferred on 12/11/15.

On a follow-up consultation report by provider #1 dated 12/10/15, the provider indicated that the patient continued with psychiatric symptoms and "inpatient psychiatry remains in effect". Also written was that provider #1 "discussed this patient's case with the inpatient care specialist." Until the patient was transferred to the BHU on 12/11/15, no documentation of psychiatric assessments, treatments, therapies, or progress notes were completed.

Provider #1 was interviewed on 12/22/15 at 1:30 pm. During this interview provider #1 stated that he discussed this patient with the inpatient care specialist and that the inpatient provider would make decisions for treatment (medications specifically mentioned) when the patient was transferred back to the BHU where the patient could be monitored. This provider also confirmed that inpatient psychiatric patients are "rounded on" and assessed daily and progress notes are written for all admitted psychiatric patients.

Staff failed to meet the psychiatric needs of patient #1, according to care guidelines/policies for the inpatient psychiatric unit, while this patient was on the medical/surgical unit waiting for a BHU bed to become available. This failure resulted in a delay in treatment for the patient's diagnosed psychiatric condition and symptoms.