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DES PERES HOSPITAL 2345 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 March 8, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interviews, the hospital failed to provide stabilizing treatment within its capacity and capability for one (#16) of 22 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical condition (EMC), out of sample selected from 10/04/16 through 03/07/17.

Please see A2407 for details.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to provide stabilizing treatment within its capacity and capability for one patient (#16) of 22 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical condition (EMC), out of a sample of closed medical records selected from 10/04/16 through 03/07/17. The average number of patients seen in the ED was 26 per day. The ED average yearly census was 9,490. The facility census was 52.

Findings included:

1. Review of the hospital policy titled, "EMTALA" dated, 11/25/14, showed the following:

- Emergency Medical Condition (EMC) was a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could result in either placing the health of the individual in serious jeopardy, or serious dysfunction of any bodily organ or part;

- Stabilized means with respect to an EMC, that no material deterioration of the condition is likely, with reasonable medical probability, to result from or occur during the transfer;

- The hospital will provide to an individual who is determined to have an EMC, such further medical examination and treatment as was required to "Stabilize" the EMC;
- When the hospital transfers an individual with an unstable EMC to another hospital, the hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual's health;

- A representative of the receiving hospital must confirm that available space and qualified personnel to treat the individual, are available; and

- The receiving hospital agrees to accept transfer of the individual.

Review of hospital policy titled, "Overdose Ingestion-Protocol for ED" revised, 01/2016, showed in part, contact with Poison Control for consultation was part of the assessment process, along with starting intravenous (IV) fluids, physician notification and "if ingestion occurred more than 1 hour prior to arrival and patient is alert or easily arousable, continue to monitor closely."

2. Review of Patient #16's medical record at Hospital A showed the following:

- On 02/27/17 at 4:05 PM, Patient #16, a [AGE] year old presented to the emergency department with a family member after intentionally overdosing on Tylenol (if administered early, the antidote to a Tylenol overdose can prevent liver failure, an emergency medical condition). Further documentation showed that patient # 16 had pressured (rapid, frenzied) speech, was restless, agitated, belligerent, and suicidal, complained of abdominal pain, and vomiting. ED Nurse F documented Patient # 16 required one-to-one observation and suicide precautions were initiated;

- At 4:41 PM the ED Nurse F triaged (assign urgency toward ill patients) Patient #16, and noted the patient had intentionally ingested 100 tablets of Tylenol approximately 27 hours prior to arriving at the ED (1:00 pm on 02/26/17);

- At 4:45 PM, laboratory drew blood from patient # 16 for testing which showed abnormally high levels >2600 IU/L (international units per liter) of two liver enzymes ALT and AST, which are indicators of liver damage or injury (normal levels are 1-31 IU/L). Additional test results indicated a high 2.6 mg/dl (normal 0.0 - 1.0) level of Bilirubin (test to diagnose and monitor diseases of the liver) and a high 72.7 mcg/mL (normal 15.0-20.0) Acetaminophen level (Tylenol);

- At 4:46 PM, the ED Nurse F performed a Suicide Screening assessment and documented that patient # 16 required one to one observation;

- At 4:50 PM the ED nurse documented Patient # 16 walked out of the ED treatment room and stated she was leaving.

- At 4:57 PM, ED Physician H documented patient # 16 confirmed having taken a substantial amount of Tylenol on 02/26/17 in an attempt to kill herself;

- At 5:05 PM, ED Physician H documented "significant" abnormalities in patient # 16's lab tests. Further documentation showed that patient # 16 abruptly ran out of the ED treatment area and informed the nurses that she had changed her mind about seeking care regardless of the consequences, including death due to liver failure. Hospital security and police were called to detain patient # 16. Further documentation showed that ED Physician H completed an affidavit to support involuntary commitment for psychiatric evaluation and care and directed that patient # 16 be taken to Hospital B's ED, the "closest higher level of care facility with inpatient psychiatric capability."

The medical record did not contain evidence that the hospital provided treatment within its capabilities and capacity to prevent or mitigate patient # 16's acute liver failure or contact poison control for instructions on treating a Tylenol overdose. The acute care hospital's capabilities included 140 + inpatient beds, an ED with staff available to respond and treat overdoses, a medical/surgical intensive care unit and the availability of gastroenterologists that specialize in the management of diseases of the gastrointestinal track and liver. Review of the 2/27/17 Ambulance Report indicated EMS arrived at the hospital at 5:13 PM and departed with Patient # 16 at 5:31 PM, one and a half hours after the patient presented to the ED with an emergency medical condition seeking treatment that was not provided by the hospital prior to transport to Hospital B.

During an interview on 03/08/17 at 12:30 AM, and continued at 3:42 PM, ED Nurse Director F, stated that:

- He triaged Patient #16 around 4:00 PM on 02/27/17, with complaints of swallowing 100 of Tylenol 500 milligram tablets around 1:00 PM on 02/26/17;
- He contacted RN, House Supervisor G, and told her that Patient #16 was Suicidal and required a close observation (clarified as one to one, someone who does not leave the patient's side);
- He took Patient #16 to treatment room six, completed a safety room check, got a patient belonging bag, and paper scrubs;
- House Supervisor G arrived to treatment room six, Nurse G was given report, the patient was changed into paper scrubs, and laboratory drew blood;
- He did not call Poison Control for recommendations for treatment of Tylenol overdose;
- He saw Patient #16, walk out through the triage area, and into the waiting room, followed by Nurse G;
- "In my eyes, the patient is not allowed to leave";
- He called Law Enforcement, the hospital's Chief Nursing Officer, and Risk Management;
- He called Law Enforcement because the patient was "still our patient and wanted help getting the patient back into a treatment room";
- Patient #16 never re-entered the ED for treatment;
- Patient #16 was in the waiting room, had changed into her personal clothes, and there were five Law Enforcement officers, two were acting EMS;
- Patient #16 told the law Enforcement that she wanted to leave AMA;
- He told the Law Enforcement that Patient #16 could not leave AMA, because the patient was a harm to herself;
- Emergency Medical Service (EMS) and Law Enforcement placed Patient #16 on an EMS gurney and hand cuffed the patient;
- Staff A, Director of Patient Safety, informed him that ED Physician H spoke to a Physician at Hospital B, and patient # 16 left the hospital via EMS.
- Patient #16 had arrived at Hospital B when the triage report, the laboratory results, affidavit, and remaining portions of the ED medical record were faxed to Hospital B;
- "Patient #16 was unstable from a psychiatric standpoint, and when we got the laboratory results, the patient was not medically stable either"; and
- He did not fax the transfer paperwork because ED Physician H did not sign the transfer paperwork.

During an interview on 03/08/17 at 2:46 PM, Nurse G, House Supervisor stated that:

- She received a call from ER Nurse Director F, to be a constant observer for patient # 16;
- Constant observers are called for any time someone had an attempted suicide;
- Patient #16 attempted to leave after ED Physician H performed a medical screening exam (MSE), grabbed her clothes, and walked out the ED waiting room door;
- The patient changed from paper scrubs to her own clothes outside the waiting room doors;
- Patient #16 never left Nurse G's line of sight, and the patient never left hospital property;
- Nurse G stated, "we have the capability to restrain patients, but the patient was not restrained because she was already in the waiting room";
- Historically, we would not allow a patient with an unstable psychiatric and medical emergency to leave like this; and
- Nurse G stated it was her responsibility to complete a checklist for EMTALA forms, but did not do this for Patient #16.

During a telephone interview on 03/08/17 at 11:00 AM, Hospital Security Officer E, stated that:

- He was called to the ED to assist with Patient #16 and he arrived about the same time Law Enforcement arrived;
- Patient #16 did not refuse treatment at the hospital;
- "I have no idea why she wasn't taken back into the ED";
- He could restrain a patient to keep the patient from harming self or others; and
- Law Enforcement stated the patient was placed in handcuffs, to keep her safe.

During an interview on 03/08/17 at 1:10 PM, ED Physician H, stated that:

- Upon examination, Patient #16 stated that she had taken 50 grams (unit of measurement) of Tylenol to kill herself;
- Patient's right upper abdomen was tender;
- The patient's abdominal tenderness was consistent with a Tylenol overdose;
- "The pressing issue was Patient # 16's medical and psychiatric instability;
- Patient #16 could not leave against medical advice (AMA);
- When Law Enforcement became involved, they are in charge;
- Law Enforcement I, made the decision to transfer Patient #16 to Hospital B; and
- We completed the paperwork for transfer "best we could, not knowing exactly what the right thing to do was".

During a telephone interview on 03/08/17 at 1:57 PM, Law Enforcement I, stated that:

- The patient was in the waiting room and started to get loud;
- Patient #16 was placed in handcuffs for her safety and was never arrested;
- The ED staff never assisted law enforcement, the ED staff had to be found, "as they just kind of left, security was there, but didn't know really what to do";
- The hospital just said that they couldn't admit her because they didn't have a psychiatric ward; and
- "I felt the ED did not want to take the patient back into the ED".

During a telephone interview on 03/08/17 at 3:33 PM, EMS J, stated that EMS transported Patient #16 to Hospital B after Staff A, Director of Patient Safety, gave them approval.

During an interview on 03/08/17 at 4:33 PM, Staff A, Director of Patient Safety, stated that:

- She arrived to ED waiting room, Patient #16 was on an EMS gurney;
- She spoke with ED Nurse Director F, and was informed that the Medical Screening Exam (MSE) had been completed;
- She asked ED Nurse Director F if "We talked to Hospital B", but did not clarify what information was exchanged;
- She spoke with EMS J, and informed him that the hospital had completed a MSE and an affidavit, and told EMS J that the patient could be taken to Hospital B;
- "In my mind" I thought Staff H, Physician, talked to Hospital B's physician, however, he did not talk to physician at Hospital B;
- When we have a psychiatric transfer, we want to medically clear the patient first; and
- Regarding the patient's disposition of Against Medical Advice (AMA), it should have never been documented that way.

During an interview on 03/08/17 at 4:19 PM, ED Charge Nurse K, stated she documented in the medical record that Patient #16 left AMA and that ED Nurse Director F directed her to do so.

3. Review of Patient #16's 2/27/17 medical record at Hospital B showed that staff contacted Poison Control and received recommendations for administering Acetylcysteine (the antidote medication for treating an overdose of Tylenol). Further documentation showed that Patient # 16 was admitted to an intensive care unit (unit in the hospital where seriously ill patients are cared for by specially trained staff) for treatment to stabilize her emergency medical condition.