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.

POPLAR BLUFF REGIONAL MEDICAL CENTER 3100 OAK GROVE ROAD POPLAR BLUFF, MO 63901 June 14, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and record reviews, the hospital failed to follow their policies and did not provide within its capabilities the appropriate stabilizing treatment to one (Patient #11) of 22 patients selected for review from the Emergency Department (ED) log (December 2011 to June 2012).

Findings Included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" Policy," effective 09/15/08, showed the following on page 1 of 22:
1) Any individual who comes to the hospital's Dedicated Emergency Department and on whose behalf a request is made for examination or treatment for a medical condition will be provided with:
a) an appropriate medical screening examination within the Emergency Department's capabilities, including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exits;
b) any necessary treatment to stabilize an emergency medical condition within the capabilities of the staff and facilities, including ancillary services routinely available to the ED, prior to discharge or transfer; and/or
c) an appropriate transfer, if necessary.
On page 7 of 22 the policy continues and at section 7 a (1-3) defines an emergency medical condition (EMC) 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 reasonably be expected to result in placing the health of the individual ... in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part ...

Review of a second policy titled, "Evaluation and Treatment of the Psychiatric Patient, Emotionally Disturbed Patient or Impaired Patient in the Emergency Department,"last revised 01/12, showed the following:
- Psychiatric emergencies are characterized by abnormal behavior such as destructive behavior.
- Care should be aimed at calming the situation and/or behavior that led to presentation to the emergency department.
- Risk Grouping: Emergent Risk-Intervention Required Within 30 Minutes
- Evidence of continuing psychiatric illness such as depression, schizophrenia, personality disorder with a history of psychiatric illness or treatment
- Aggressive and/or violent behavior
- Symptoms of instability (pacing, muttering, clenched fist, etc.)

2. Review of Patient #11's closed ED medical record dated 06/07/12 showed the following:
- A pre-hospital Transfer Form from the Residential Care Facility (RCF) dated 06/07/12 at 8:15 AM showed the following:
- "Resident has attacked staff, hitting them with his fists. He has been yelling and screaming all morning, threatening staff and residents. He is requesting to go to the hospital."
- Usual Mental Status (Prior to this Episode): "Confused, demented, agitated, assaultive, wanders." And "Has diagnosis of schizoaffective disorder and has mental issues and is currently delusional."
- At Risk For: "Harm to self, harm to others."

- Review of the Ambulance Report showed the following:
- Dispatch Reason: "Combative" at RCF.
- "Patient standing outside smoking and appeared to have altered level of consciousness."
- "Patient appears to be suffering from dementia. Thinks he is Al Capone, and talks to president often."

- Review of the ED record also showed:
- Patient #11 arrived at the emergency room (ED) via ambulance at 8:55 AM.
- A notation at 9:44 AM by the Physician Assistant (PA) showed the patient presented to the ED "with psychosis (a mental disorder in which paranoia, persistent delusions, and hallucinations are a prominent feature), had experienced auditory hallucinations, had experienced visual hallucinations, and had delusions. Onset: the symptoms/episode began/occurred at an unknown time. Past psychiatric history: Prior diagnosis: schizophrenia (a severe, lifelong brain disorder, people may hear voices, see things). The patient had experienced similar episodes in the past, chronically. Was violent at RCF scuffled with staff and was struck in ear, sustaining superficial laceration."
- A notation at 9:52 AM by the ED physician showed "Behavior/mood is aggressive, inappropriate for age, affect is animated. Judgment/insight is impaired. Delusions/hallucinations are present and described as: Patient is German spy working for White House, persecuted by nursing home staff because he knows about them. He has been having conversations with multiple individuals since being in ED including the President..."
- A notation by the ED nurse at 9:53 AM showed "Patient carries on conversation with 'the president' on the phone. States he is a German spy working for the White House. Patient does become agitated and aggressive from time to time while on the 'phone.' Patient has no phone in the room or on his person."
- A notation at 11:42 AM showed the Qualified Mental Health Provider (QMHP) documented telephone contact with the on call psychiatrist who determined that Patient #11 could be discharged because he did not meet psychiatric inpatient admission criteria. At 2:02 PM the ED physician documented orders for discharge. Further documentation revealed the RCF refused to allow Patient #11 to return. Patient #11 remained in the ED without stabilization of his psychiatric emergency (chronic schizoaffective disorder with paranoia, delusions, auditory and visual hallucinations, and violent outburst). At 11:57 PM, documentation revealed Patient #11's legal guardian and the deputy Sherriff arrived to transport him to a family member's home after receiving a dose of Zydis (a medication to prevent aggressive behavior).

3. Review of patient roster revealed the hospital's Behavioral Health Unit (BHU) includes 40 beds and that the total census on 6/7/12, the day Patient #11 presented to the ED, was 21.

4. During an interview on 08/21/12 at 8:10 AM, Patient #11's state appointed patient advocate stated she and the RCF Administrator went to the hospital on the evening of 06/07/12 to facilitate getting Patient #11 admitted to an appropriate healthcare provider because the hospital refused to admit him. At approximately 8:30 PM, the patient said he needed to use the restroom. He was on 1:1 observation. ED staff escorted him to the restroom. The patient advocate stated that when he returned to his room in the ED, she observed him sit down in a chair and urinate on the floor. Patient #11 then became loud with one of the ED staff, "banged" on a TV, and yelled something to the effect of "There! Tell that to President Obama!" At that point, she stated Staff D, ED Director, came into the room and said, "Ma'am, you're gonna have to do something with him because he is a threat to my staff." As the patient's behaviors escalated, the patient advocate and RCF Administrator asked the evening shift QMHP, Staff N, to do a second mental health assessment. The patient advocate stated Staff N refused, stating he would not undermine another QMHP's assessment.

Refer to tag A2407 for further details.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on interviews and record reviews, the hospital failed to provide stabilizing treatment within its capabilities to one patient (Patient #11) with a psychiatric emergency out of 22 patients selected for review from the Emergency Department (ED) log (December 2011 to June 2012).

Findings Included:

1. Review of Patient #11's closed ED medical record dated 06/07/12 showed the following:
- A pre-hospital Transfer Form from the Residential Care Facility (RCF) dated 06/07/12 at 8:15 AM showed the following:
- "Resident has attacked staff, hitting them with his fists. He has been yelling and screaming all morning, threatening staff and residents. He is requesting to go to the hospital."
- Usual Mental Status (Prior to this Episode): "Confused, demented, agitated, assaultive, wanders." And "Has diagnosis of schizoaffective disorder and has mental issues and is currently delusional."
- At Risk For: "Harm to self, harm to others."

- Review of the Ambulance Report showed the following:
- Dispatch Reason: "Combative" at RCF.
- "Patient standing outside smoking and appeared to have altered level of consciousness."
- "Patient appears to be suffering from dementia. Thinks he is Al Capone, and talks to president often."

- Review of the ED record also showed:
- Patient #11 arrived at the emergency room (ED) via ambulance at 8:55 AM.
- A notation at 9:44 AM by the Physician Assistant (PA) showed the patient presented to the ED "with psychosis (a mental disorder in which paranoia, persistent delusions, and hallucinations are a prominent feature), had experienced auditory hallucinations, had experienced visual hallucinations, and had delusions. Onset: the symptoms/episode began/occurred at an unknown time. Past psychiatric history: Prior diagnosis: schizophrenia (a severe, lifelong brain disorder, people may hear voices, see things). The patient had experienced similar episodes in the past, chronically. Was violent at RCF scuffled with staff and was struck in ear, sustaining superficial laceration."
- A notation at 9:52 AM by the ED physician showed "Behavior/mood is aggressive, inappropriate for age, affect is animated. Judgment/insight is impaired. Delusions/hallucinations are present and described as: Patient is German spy working for White House, persecuted by nursing home staff because he knows about them. He has been having conversations with multiple individuals since being in ED including the President..."
- A notation by the ED nurse at 9:53 AM showed "Patient carries on conversation with 'the president' on the phone. States he is a German spy working for the White House. Patient does become agitated and aggressive from time to time while on the 'phone.' Patient has no phone in the room or on his person."
- An assessment by Staff M, Qualified Mental Health Provider (QMHP) at 10:20 AM showed the following:
- Became aggravated at the Nursing Home. Report states the patient attacked staff - hit them with his fists, yelling and screaming all morning, threatening staff and residents. Patient requested to go to the hospital.
- Patient argumentative, lying prone in bed, eyes closed, hands in jacket pocket.
- "I don't want to go back there."
- "Delusions" and behavior consistent with chronic issue.
- Thought processes: Preoccupations - Wants to move to a new facility.
- Mood: Irritable - Angry with facility (assisted living), feels disrespected.
- Two previous inpatient hospitalization s were noted: 02/08/12 - 02/14/12 and 03/26/12 - 04/02/12. One admission was for medication adjustment and one admission was for alcohol intoxication after he drank "significant quantities of body spray, which contained alcohol."
- A notation at 11:42 AM showed the QMHP documented telephone contact with the on call psychiatrist who determined that Patient #11 could be discharged because he did not meet psychiatric inpatient admission criteria. At 2:02 PM the ED physician documented orders for discharge. Further documentation revealed the RCF refused to allow Patient #11 to return. Patient #11 remained in the ED without stabilization of his psychiatric emergency (chronic schizoaffective disorder with paranoia, delusions, auditory and visual hallucinations, and violent outburst). At 11:57 PM, documentation revealed Patient #11 ' s legal guardian and the deputy Sherriff arrived to transport him to a family member's home after receiving a dose of Zydis (a medication to prevent aggressive behavior).

2. During an interview on 08/22/12 at 3:00 PM, Staff J, ED Registered Nurse (RN), stated that on the evening of 06/07/12, he was functioning as the Charge Nurse (being a resource to all ED staff) as well as being the Triage Nurse. Staff J stated he recalled Patient #11, and that the patient took offense to being accompanied to the restroom and sat in a chair and urinated.

During an interview on 08/21/12 at 8:10 AM, Patient #11's state appointed patient advocate stated she and the RCF Administrator went to the hospital on the evening of 06/07/12 to facilitate getting Patient #11 admitted to an appropriate healthcare provider because the hospital refused to admit him. At approximately 8:30 PM, the patient said he needed to use the restroom. He was on 1:1 observation. ED staff escorted him to the restroom. The patient advocate stated that when he returned to his room in the ED, she observed him sit down in a chair and urinate on the floor. Patient #11 then became loud with one of the ED staff, "banged" on a TV, and yelled something to the effect of "There! Tell that to President Obama!" At that point, she stated Staff D, ED Director, came into the room and said, "Ma'am, you're gonna have to do something with him because he is a threat to my staff." As the patient's behaviors escalated, the patient advocate and RCF Administrator asked the evening shift QMHP, Staff N, to do a second mental health assessment. The patient advocate stated Staff N refused, stating he would not undermine another QMHP's assessment.

During an interview on 08/06/12 at 3:45 PM, Patient #11's legal guardian stated he was notified on June 7, 2012 that the patient needed to be picked up from the hospital ED because the nursing home would not take him back. The legal guardian stated he asked the deputy Sheriff to assist in transporting Patient #11 to a family member's home because he was told the patient had hit someone. The legal guardian stated that Patient #11 talked non-stop during the drive and that neither he nor the deputy Sheriff could understand the patient's conversation because it was nonsensical. "At times the patient would stop talking and say something like, 'Ask your mama. Your mama knows. She'll know about it.'" The guardian further stated that during the ride, the patient talked to the President on an imaginary phone, talked about work he had done in the past (in jobs the guardian knew he never had and wars he had never fought in), talked about serving in the Korean War and World War II, fighting the Nazis, etc." The guardian stated that the officer told him that he had transported a lot of psychiatric patients but had never been with someone like this.

3. Review of the hospital's Behavioral Health Unit (BHU) policy titled, "Admission Criteria," effective 07/01/11, showed the following direction:
A. The following is criteria used in deciding whether to admit an adult patient for inpatient psychiatric care:
b. With active treatment, an improvement in the patient's level of functioning can be anticipated.
2. One or more of the following must also be present:
a. The patient poses an actual or imminent danger to self, others, and/or property due to the manifestations of a psychiatric disorder.
b. The patient needs continuous skilled observation and/or evaluation and/or treatment available only in a hospital.
c. Due to a psychiatric disorder, the patient is impaired to the degree that he or she manifests major disability in social, occupational, and/or familial functioning and this impairment cannot be managed in a less intensive setting.
3. In addition to the above, the patient presents with one or more of the following:
b. The failure of outpatient treatment and/or management has been verified.
e. The patient manifests significantly impaired reality testing.
f. The patient manifests significantly impaired judgment and/or logical thinking which is amenable to treatment.
g. The patient manifests a significant affective disturbance.
k. The patient needs the 24-hour structured therapeutic environment provided in a hospital.

Documentation in the medical record indicated Patient #11 met the admission criteria for the hospital's 40 bed psychiatric unit as specified by the BHU policy titled, "Admission Criteria." Review of the BHU patient roster revealed the unit had 40 beds and that the census on the day Patient #11 presented to the ED, 06/07/12, was 21.