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SOUTHCOAST HOSPITALS GROUP 363 HIGHLAND AVENUE FALL RIVER, MA 02720 Feb. 24, 2011
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Base on documentation review it was determined Patient #1 ' s 2/11/11 presentation to Hospital #1 ' s ED was not recorded on the corresponding ED log.

Findings included:

Please see Tag A-2406 for information related to Patient #1 and his/her 2/11/11 ED presentation.

Review of the 2/11/11 ED log did not indicate Patient #1 ' s name appeared on the log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and documentation review it was determined Hospital #1 failed to provide a MSE to Patient #1 on 2/11/11.

Findings included:

The Triage Nurse was interviewed in person on 2/24/11 at 12:00 PM. The Triage Nurse said at the same time Police Officer #1 approached the triage desk a telephone call was received from a near by Mental Health Center reporting there would be a patient arriving with police officers. The Triage Nurse said he/she replied they were here now (in Hospital #1's ED waiting area) and Police Officer #1, who was standing at the desk, asked if it was the Mental Health Center on the phone and stated he/she wanted to speak with them; upon which the phone was handed over to Police Officer #1. The Triage Nurse said he/she left the triage desk briefly and upon returning Police Officer #1 reported Patient #1 had, earlier that day, eloped from Hospital #2 and that they (the police officers) had had to sweet talk Patient #1 into coming to Hospital #1. The Triage Nurse said he/she stated to Police Officer #1 that it seemed that since Patient #1 had eloped from Hospital #2 the police had brought Patient #1 back to the wrong place; however they (Hospital #1) would be happy to see Patient #1 but for continuity of care it did seem that Patient #1 belonged at Hospital #2. The Triage Nurse said at this point two individuals sitting in the ED waiting area got up and walked out accompanied by Police Officer #2, who had also been in the waiting area, along with Police Officer #1.

There was no medical record associated with Patient #1 ' s 2/11/11 ED presentation.

Review of Patient #1 ' s medical record from Hospital #2 indicated on 2/11/11, at 9:58 PM Patient #1, under a section 12a (Application that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed), was brought to Hospital #2 ' s ED and received a MSE including medical and psychiatric evaluations. Patient #1 was determined to require an in patient psychiatric admission and a bed search was conducted. However while waiting for a psychiatric bed to be available Patient #1 stabilized and was discharged home, with comprehensive community services, from the ED on 2/15/11.