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.

MERCY HOSPITAL JEFFERSON 1400 US HIGHWAY 61 FESTUS, MO 63028 April 17, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility did not perform a Mediical Screening Examination (MSE) on one patient (Patient # 3), within the hospital's capability sufficient to determine if an emergency psychiatric condition existed, out of a sample of 30 Emergency Department (ED) patient records reviewed from 9/1/12 to 4/4/13. The hospital sees an average of 2700 emergency room cases per month.

Findings included.

1. Record review of the hospital's Policy titled "Emergency Medical Treatment And Labor Act" revised 09/12, showed the following staff direction:
-Any individual on JRMC premises requesting emergency care is entitled to a medical screening examination (MSE) and stabilizing treatment.
-The Emergency Department provides any individual who comes to the emergency department an appropriate medical screening examination within the capability of JRMC emergency department.
-A medical screening examination is the process of determining whether a medical emergency does or does not exist. The medical screening examination may range from a simple exam to a complex exam. A simple exam includes only a brief history and physical examination. A complex exam may include, but is not limited to, ancillary studies and procedures such as lumbar punctures, clinical laboratory tests, CT scans, and /or diagnostic tests and procedures.
-Emergency Medical Condition is defined as 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 be reasonably expected to result in:
-Placing the health of the individual in serious jeopardy;
-Serious impairment to any bodily functions;
-Serious dysfunction of ant bodily organ or part
Further medical examination and treatment, as required to stabilize the medical condition means to assure, within reasonable medical probability, that no material deterioration is likely to occur. A patient is deemed stabilized if the treating physician attending to the patient in the emergency department/hospital has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved.


2. Review of a closed medical record from an outside facility (Residential Care Facility-RCF) dated Wednesday 01/23/13 showed that Patient #3 was extremely paranoid, his behavior was escalating and threatening, and causing other residents and staff to fear for their safety. Further documentation showed that Patient #3 refused medication adjustment prescribed by his psychiatrist, refused recommended hospitalization and was subsequently discharged (time unknown).

3. Review of a closed medical record showed Patient #3 presented to Mercy Hospital Jefferson on Friday 01/25/13 at 10:35 AM complaining of chronic back pain and generalized pain. Documentation showed that the patient reported he got into an altercation with his psychiatrist about medications, police were notified (on 01/23/13) and he was discharged from the residential facility. Further documentation showed Patient #3 had been out of his medications since Wednesday. The ED nurse practitioner contacted the residential facility and confirmed Patient #3 had been discharged (on Wednesday) without his psychiatric and pain medications, that his primary care physician was out of the country and that the physician's nurse practitioner had refused to order a refill of Patient #3's medications. The patient's psychiatric history included schizophrenia (a chronic, severe, disabling brain disorder), anxiety and manic depression (a serious mood disorder characterized by dramatic mood swings). During the physical examination, the ED nurse practitioner found the patient to be agitated. At 11:17 AM the ED nurse practitioner wrote orders for discharge. The patient's discharge instructions specified "We are unable to refill your psychiatric or your chronic pain medications today in the emergency room ." The patient refused to sign the discharge instructions and refused to leave the ED. The ED staff administered a pain pill to the patient and contacted hospital security who escorted him out of the ED at 12:11 PM. The medical record did not contain evidence that the ED nurse practitioner examined Patient #3 to assess his mental illness or evaluated his complaints of pain to determine whether he had an emergency medical condition.

4. Review of a closed medical record showed Patient #3 returned to the ED on Saturday 01/26/13 at 1:49 PM, approximately 24 hours after discharge. ED physician Q examined Patient #3 and documented the patient complained of shortness of breath, difficulty walking, sleeping and stress. ED physician Q ordered testing of Patient #3's blood and urine. A psychiatric assessment, completed by mental health professional GG, documented contact with the RCF for collateral information and that Patient #3 had been verbally aggressive toward others, had threatened to harm others (at the RCF on Wednesday 01/23/13), had symptoms of psychosis (loss of contact with reality), symptoms of anxiety (excessive worry), symptoms of a manic episode (grandiose, flight of ideas, constant movement, excessive speech), that the patient was non-compliant with his medications, and had symptoms of alcohol and substance abuse. ED physician Q documented Patient #3 was admitted to the behavioral health unit for bipolar disorder (brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and paranoid schizophrenia (a form of schizophrenia characterized by believing things that are not true).

5. During an phone interview on 04/18/13 at 5:25 PM, Staff N, ED Nurse Practitioner, stated that Patient #3 came into the ED on Friday, 01/25/13, for back pain and everything was normal. Nurse practitioner N stated that she was aware the patient had a history of manic depressive disorder and schizophrenia because the residential home told her about the patient's history when she contacted them. Nurse practitioner N also stated that the patient requested a refill of his psychiatric medications, "but I was seeing him for back pain and not for a psychiatric issue". Nurse practitioner N stated that she has the "ability to contact psych intake if necessary" and that she has done it before. When asked if Nurse practitioner N was aware of the patient becoming agitated in the ED, she couldn't remember.

6. During an interview on 04/18/13 at 11:16 AM, Staff T, ED RN, stated that when Patient #3 came to the ED on Friday, 01/25/13, he was concerned that that the patient may become violent, so he observed the patient when another nurse went into his room. ED nurse T stated that the patient was very loud and when ED nurse T tried to explain things to him, the patient couldn't understand what he was saying.

7. Record review of the facility's policy titled, "Psychiatric Patient" revised 10/12, showed that if the patient presents a danger to self or others, assessment and documentation shall include the patient's history, complaint, observation of signs and symptoms of mental, emotional, behavioral or suspected substance abuse, potential danger to self, staff or others, current plans for suicide and/or history of suicide and completion of the Patient/Staff Safety Checklist.

8. Review of the ED on call list revealed a psychiatrist was on call and available when Patient #3 (MDS) dated [DATE]. Review of the census for the behavioral health unit revealed there were 10 available beds when Patient #3 (MDS) dated [DATE].

The facility failed to follow policy for Patient #3, a patient with a psychiatric history who did not have access to his psychiatric medications and who complained of chronic back pain and generalized pain. The nurse practitioner did not contact a mental health professional or complete a psychiatric examination or evaluate the cause of patient # 3's pain prior to his discharge from the ED on Friday 1/25/13.
See Tag A2406 for additional details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and record review, the facility failed to provide an adequate Medical Screening Exam (MSE) for one patient (Patient #3) within the hospital's capability to determine if an emergency medical condition (EMC) existed, out of a sample of 30 Emergency Department (ED) patient records reviewed from 09/01/12 to 04/04/13. The hospital sees an average of 2700 emergency department cases per month.

Findings included:

1. Review of a closed medical record from an outside facility (Residential Care Facility - RCF) dated Wednesday 01/23/13 showed that Patient #3 was extremely paranoid, his behavior was escalating (increasing in severity and intensity), threatening, and causing other residents and staff to fear for their safety.
Further documentation showed that Patient #3 refused medication adjustment to stabilize his mental illness, refused recommended hospitalization and was subsequently discharged (time unknown).

2. Review of a closed medical record showed Patient #3 presented to Mercy Hospital Jefferson on Friday 01/25/13 at 10:20 AM, two days after discharge from the RCF. At 10:24 AM ED nurse EE documented Patient #3 had a history of psychiatric problems which included depression, anxiety, and manic depression (a serious mood disorder characterized by dramatic mood swings). At 11:09 AM, ED nurse practitioner N documented that Patient #3 presented to the ED complaining of "chronic back pain and generalized pain." Further documentation by ED nurse practitioner N showed that the patient was discharged from the RCF without his pain and psychiatric medications; that his primary doctor was out of the country; and that the primary doctor's nurse practitioner refused to fill his pain medications. ED nurse practitioner N documented Patient #3 had a history of depression and was agitated, that she contacted the RCF and was told that Patient #3 had been discharged without psychiatric or pain medications; that the patient had fired his psychiatrist; that he had a history of manic depressive disorder, schizophrenia (a chronic, severe, disabling brain disorder); and that he abused his narcotic pain medication. At 11:17 AM the ED nurse practitioner discharged Patient #3 and instructed him that the ED was unable to refill his psychiatric or chronic pain medications. At 11:33 AM ED nurse S documented Patient #3 refused to sign his discharge instructions; that he requested a prescription for his pain medicine and that she consulted with the ED nurse practitioner. At 12:11 PM ED nurse U documented Patient #3 received one prescription pain pill and that hospital security was contacted to escort him out of the ED. The ED medical record did not contain evidence that Patient #3 received a mental health examination to assess his mental illness or an evaluation of his complaints of pain to determine whether he had an emergency medical condition.

3. Documentation provided by the hospital showed a psychiatrist was available and on call to the ED on 01/25/13. Review of the Behavioral Health Services outpatient staffing showed that between 6:45 AM and 7:15 PM on 01/25/13 two intake coordinators were staffed to cover psychiatric evaluations in the hospital. Review of the Behavioral Health Services Unit midnight census sheet dated 01/25/13 showed there were between 14 and 15 inpatients out of 24 available beds on "2 North" (adult psychiatric unit) during the time Patient # 3 was in the ED.

4. During an interview on 04/16/13 at 12:20 PM, the Medical Director of the Psychiatry Unit stated that "unfortunately" psychiatry was not consulted when Patient # 3 was in the ED on Friday 1/25/13. " Without the psychiatric medications for a bipolar patient (also known as manic depression), anything can happen." "Before we sent him home, the patient should have been assessed for hallucinations or delusions, but the documentation does not indicate this was done."

During a phone interview on 04/18/13 at 5:25 PM, Staff N, ED Nurse Practitioner, stated that she saw Patient #3 on Friday, 01/25/13, for back pain and everything was normal. Staff N stated that she was aware the patient had a history of manic depressive disorder and schizophrenia because the residential home told her about the patient's history when she contacted them. Staff N also stated that the patient requested a refill of his psychiatric medications, "but I was seeing him for back pain and not for a psychiatric issue". Staff N stated that she has the "ability to contact psych intake if necessary" and that she has done it before. When asked if Staff N was aware of the patient becoming agitated in the ED, she couldn't remember.

During a phone interview on 04/23/13 at 8:39 AM, Staff U, ED Charge Nurse stated that on Friday, 01/25/13, Patient #3 was agitated. He would repeatedly sit on the bed and then get up again. Staff U stated that she was trying to explain things to Patient #3, but he was unable to understand because he was so irrational. Patient #3 became so loud that other staff observed him to ensure that the patient didn't escalate out of control.

During an interview on 04/18/13 at 11:16 AM, Staff T, ED RN, stated that when Patient #3 came in on Friday, 01/25/13, he was concerned that the patient may become violent, so he observed the patient while a nurse was in the room with the patient to ensure the nurse was safe. Staff T stated that the patient was very loud and when Staff T tried to explain things to him, the patient couldn't understand what he was saying.

During an interview on 04/22/13 at 8:37 AM, hospital security officer EE stated he was called to the ED on Friday 1/25/13. Officer EE described Patient #3 as "kind of irate and kind of upset." "The (emergency room ) wanted him out of there." "He (Patient #3) really wanted to talk to the doctors but the ED staff said no you've been discharged ."

Review of a closed medical record showed Patient #3 returned to the ED on Saturday 01/26/13 at 1:49 PM, approximately 24 hours after discharge. ED physician Q examined Patient #3 and documented the patient complained of shortness of breath, difficulty walking, sleeping and stress. ED physician Q ordered testing of Patient #3's blood and urine. A psychiatric assessment, completed by mental health professional GG, documented contact with the RCF for collateral information and that Patient #3 had been verbally aggressive toward others, had threatened to harm others (at the RCF on Wednesday 01/23/13), had symptoms of psychosis (loss of contact with reality), symptoms of anxiety (excessive worry), symptoms of a manic episode (grandiose, flight of ideas, constant movement, excessive speech), that the patient was non-compliant with his medications, and had symptoms of alcohol and substance abuse. ED physician Q documented Patient #3 was admitted to the behavioral health unit for bipolar disorder (brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and paranoid schizophrenia (a form of schizophrenia characterized by believing things that are not true).

During an interview on 4/16/13 at 4:36 PM, ED physician Q stated Patient #3 (on 1/26/13) looked like he hadn't slept." "The patient had been out of his medications for an unknown amount of days and was stressed out." "We can re-fill psychiatric medications for a few days ", but the patient wanted to be admitted , so psychiatry was involved. "When the psychiatric team becomes involved, they are able to dig up other things that the patient won't just share with anyone." "They spend about 30 minutes with them. Then the intake person will call the psychiatrist."