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UMASS MEMORIAL HEALTHCARE-MARLBOROUGH HOSPITAL 157 UNION STREET MARLBOROUGH, MA 01752 July 16, 2012
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interviews, the Hospital failed to ensure that a medical screening examination was provided for 1 of 20 sampled patients (Patient #2).

Findings include:

The Triage Assessment, dated 5/26/12 at 5:34 P.M., indicated that Patient #2 presented to the ED at 5:34 P.M. accompanied by staff from his/her residence for a psychiatric evaluation for suicidal ideation. The Triage Assessment indicated that Patient #2 had a plan to jump out of a car window. The Triage Assessment indicated that Patient #2 was triaged immediately as a Emergency Severity Index (ESI) Level 2 (urgent, high-risk situation).

The Policy/Procedure titled Admission Triage into the ED, effective 9/18/00 and reviewed 7/11/12, indicated that after the triage/primary nurse assessed each patient, he/she was to inform the ED Attending Physician about all patients classified as emergent ESI Level 1 and urgent ESI Level 2 status.

The Surveyor interviewed the Emergency Department (ED) Medical Director on 7/16/12 at 8:15 A.M. The ED Medical Director said patients triaged as an ESI Level 2 were to be seen by the ED Physician as soon as possible, but less than 30 minutes.

During the investigation of DPH Reference #12-0587 conducted on 6/28/12 and 7/2/12, the Surveyor interviewed the ED Nursing Director on 7/2/12 at 12:00 P.M. The ED Nursing Director said that after the Triage Nurse (could not be interviewed, moved out of state) assessed Patient #2 at 5:34 P.M. and she brought Patient #2 directly back into the ED Treatment Area and placed Patient #2 in Hall Bed C, located directly in front of the Security Station where a Security Officer was stationed. The ED Nursing Director said the Triage Nurse informed the Security Officer located at the Security Station that Patient #2 reported feeling suicidal ideation with a plan. The ED Nursing Director said the Triage Nurse wrote Patient #2's name on the white board (board located at the nursing station that listed patients and their locations in the ED), but the Triage Nurse did not put the suicidal ideation identifier ( a red magnet with a black line through it) next to Patient #2's name. The ED Nursing Director said that the Triage Nurse did not inform the Resource or Primary Nurse of Patient #2's presence in the ED.

The Hospital's Policy/Procedure titled Suicide Precautions of the Suicidal Patient in a Non-Psychiatric Setting, effective 12/24/07, indicated that when a patient was assessed to be at risk, due to potential or actual self-destructive behavior, suicide precautions were to be initiated. The Policy indicated that with suicide precautions, the patient was to be assigned to one staff member under constant observation at all times and within arm's reach. The Policy indicated that the physician was to be notified immediately.

Review of the Patient #2's ED documentation indicated that there was no indication that Patient #2 was under constant observation by an assigned staff member or that a medical screening examination was performed by the ED Physician.

The Ongoing Assessment, dated 5/26/12 at 7:45 P.M., indicated that Patient #2 "was not located in Hall Bed C, ? eloped".

The Triage Assessment, dated 5/26/12 at 7:56 P.M., indicated that Patient #2 was returned to the ED by ambulance after he/she left the ED and darted in front of a car that resulted in an injury to the left elbow.

The ED Physician Record, dated 5/26/12 at 8:00 P.M.(2.5 hours after Patient #2 presented to the ED), indicated that Patient #2 received a medical screening exam after Patient #2 was returned to the ED.

The Hospital did not ensure that Patient #2 was seen by the ED Physician and that a medical screening examination for a patient classified as an ESI Level 2 received a medical screening examination within 30 minutes as required by Policy.