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.

SSM HEALTH DEPAUL HOSPITAL ST LOUIS 12303 DEPAUL DRIVE BRIDGETON, MO 63044 Aug. 31, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and review of Emergency Department (ED) logs, Medical Records, Staffing and Physician schedules for the last four weeks, the facility failed to provide a sufficient medical screening examination within its capacity and capability for one patient (#1) of 30 patient records reviewed, who presented to the hospital Emergency Department (ED) for emergency care. The patient presented to the hospital with complaints of hand pain and possible ingestion of Phencyclidine (PCP), a hallucinogen.

The hospital had the capacity and capability to complete a medical screening examination to include further assessment of the patient's signs and symptoms to ensure that the patient was not suffering from a psychiatric emergency.

Refer to A2406 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, policy review and recorded video review, the hospital failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of a medical emergency within its capacity and capability for one patient (#1) of 30 patients' records selected from March 2017 through August 2017. The Emergency Department (ED) has an average of 6,862 emergency visits per month.

Findings included:

1. Review of the facility policy titled, "Provision of Care & Transfer/Acceptance of Patients with Emergency Medical Conditions" reviewed 07/2008 showed:

-Each individual, regardless of ability to pay for services, who requests medical treatment will receive a MSE to determine whether he/she has an emergency medical condition.
-An examination which is sufficiently detailed to reveal whether the patient suffers from an EMC or is pregnant and having contractions. Must include medically indicated screens, test, mental status evaluation, history and physical examination, etc.

-A medical condition manifesting itself by acute symptoms of severity, including labor, severe pain, psychiatric disturbances and substance abuse such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

2. Review of the pre-hospital ambulance report dated 08/21/17 at 8:29 PM showed when Emergency Medical Systems (EMS, ambulance personnel) arrived at Patient #1's residence, he was sitting in a chair on the front porch. Documentation showed the patient's family member stated the patient went out with some friends and thinks "he may have done some drugs." The family member stated that when she would not let the patient in the house, he punched his fist through the glass window. "Patient states that he does not remember this." Further documentation showed that the patient had been without his psychiatric medicines since release from prison and that he would like to be taken to DePaul hospital for evaluation. The ambulance personnel documented the patient's past medical history included schizophrenia (mental illness that can include delusions, hallucinations, trouble with thinking and concentration), an anxiety disorder, and manic/depressive. Further documentation showed the bleeding from the patient's lacerated hand was controlled and at 8:36 p.m., the patient's heart rate was abnormally fast at 120 beats per minute (normal is 60-100) and his blood pressure was abnormally elevated at 180/108 (normal range is 90/60 to 140/90). At 8:52 p.m., the ambulance arrived at the hospital emergency department (ED).

3. Review of Patient #1's medical record showed that the patient (MDS) dated [DATE] at 8:58 PM by ambulance, with complaints of hand pain after his wife reported to EMS that he had punched a window and was possibly under the influence of Phencyclidine (PCP), a hallucinogen. The patient was roomed in #25 (a psychiatric safe room) and transferred to room #27 (a psychiatric safe room near the nursing station). At 9:16 p.m. ED physician P documented the patient "voices no complaints", he denied suicidal ideation or homicidal ideation and did not want to be treated. Further documentation showed that the patient appeared intoxicated, refused to be seen, and because the patient was uncooperative, his examination was limited. The physician documented that the patient's vital signs were stable (no vital signs were documented in the medical record) and that the patient's medications included Depakote (medication to treat bipolar mania) and Seroquel (anti-psychotic medication). Two minutes later at 9:18 p.m. the ED nurse prepared documentation under the direction of ED physician P which indicated that patient # 1 was leaving against medical advice (AMA). The medical record did not contain documentation by ED physician P about the patient's hand laceration, whether the patient was off his psychiatric medications, or the benefits of an examination, or the risks of leaving prior to receiving an examination. At 9:18 p.m., the ED nurse documented that patient # 1 had to be escorted out of the ED because the patient wanted to "hang out" at the nurses' station, "informed that he will either need to leave or be treated." There was no indication in the medical record that attempts were made to obtain a blood alcohol level or a drug screen, and there was no documentation that a mental health professional was contacted for further assessment of the patient.

Record review of the Physicians Call Schedule for 08/21/17 showed a Psychiatrist was on call and available for consult to the ED.

During a telephone interview on 08/30/17 at 11:00 AM, Staff R, Registered Nurse (RN), stated that Patient #1's spouse called the ED prior to the patient's arrival and said that the patient had been away from home for several hours and when he returned he was acting strangely. Nurse R stated the spouse said she thought patient # 1 might be under the influence of PCP. He had punched a window and hurt his hand. Nurse R stated that when Patient #1 arrived at the ED, he was uncooperative with the examination, would not answer any questions, declined treatment and wanted to leave. The patient would not sign the Against Medical Advice (AMA) form, stood a the nurses' station and refused to leave, so security was contacted to escort the patient out of the facility.

During a telephone interview on 08/30/17 at 10:35 AM, ED Physician P, stated that:
- The patient was brought in by EMS for a wound to the hand after hitting a window and possible PCP ingestion.
- He refused to cooperate by answering questions fully and allowing an examination.
- He refused to sign the AMA paperwork.
- He was hanging around the nurses station and refused to leave.
- Security was called and escorted him out of the facility.

Review of the local police department's report dated 8/21/17 at 9:22 p.m. showed that a hospital security guard provided the following written statement which reads in part, "On 08/21/17 at approximately 2100 hours (9:00 p.m.), while in the Emergency Department, [security guard] observed [patient # 1] being place in Room 27." "Approximately 10 minutes later, a doctor evaluated [patient # 1] and released him from the hospital." "While signing his discharge papers, [patient # 1] began dancing and then became angry." "He approached a nurse and asked her why he was there." "[Security guard] requested for more security officers to respond to assist her." "[Security guard] grabbed [patient # 1's] right arm and began to escort him out of the building."

Review of the recorded video on 08/21/17 at 9:16:55 p.m. showed the patient was escorted from the ED by Security, approximately 18 minutes after presenting to the ED by ambulance with documentation from EMS personnel indicating the patient had been without his psychiatric medications for some time and was suspected to be under the influence of PCP.

Review of the recorded video showed the patient wandering in the parking lot, walking back and forth toward the security guards and yelling. The patient was directed multiple times to leave the property. He approached the security guards and was warned several times to stay back which he did not obey. He was tased (an electroshock weapon which fires two small dart like electrodes, which stay connected to the main unit by conductors to deliver electric current to disrupt voluntary control of muscles causing incapacitation).

During an interview on 08/30/17 at 2:26 p.m., Security Guard W stated that the patient was yelling, walking around the parking lot, jumping up and down and walking toward the ambulance bay where security was standing. He was warned repeatedly to leave the premises. He was a big man; about 6 feet 5 inches and a good 250 pounds and out of control. We (Security Guards) were in danger and had no choice but to use the taser on him.

Review of the recorded video showed the patient was brought back into the facility through the ambulance bay doors on a gurney at 9:48 p.m.,

4. Review of the medical record for the second ED presentation on 08/21/17 at 9:56 p.m. showed the patient was brought back into the hospital after being tased by a Security guard. He was treated for the one barb which was still in the skin. The patient was anxious with labile affect (rapid shifts in outward emotions) and yelling religious delusions (a belief that is held despite evidence to the contrary). The patient was evaluated and involuntarily admitted to the psychiatric unit.