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.

CITIZENS MEMORIAL HOSPITAL 1500 N OAKLAND BOLIVAR, MO 65613 July 20, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview, review of Emergency Department (ED) logs, medical records, and policies, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within its capacity and capability for four patients (#22, #21, #19 and #20) of 30 ED records reviewed from February, 2017 through July 16, 2017.

The facility had the ability to provide a MSE for Patients #19, #20, #21, and #22, to determine if they had an EMC.

Please see the citation at A2406 for further details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy review and interviews, the facility failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of a medical or psychiatric emergency, within it's capability and capacity, for four patients (#22, #21, #19, and #20) of 30 Emergency Department (ED) records reviewed. These failures had the potential to affect all patients who presented to the ED by risking the possibility of delayed treatment, injury or death for those that required immediate medical or psychiatric care. The ED evaluated an average of 1612 patients per month.

Findings included:

1. Record review of the facility policy titled, "On Call Physicians," dated 07/2016, showed that:
- A patient that presents to the ED will receive an appropriate MSE to determine if that patient has an emergency medical condition (EMC) and to treat that patient or make an appropriate transfer.
- An EMC manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical (psychiatric) attention could reasonably result in serious jeopardy to the patient.
- The EMC should be stabilized to assure that no material deterioration of the condition is likely to occur during transfer of that patient.

2. Record review of the facility policy titled, "Behavioral Assessment and Care of Psychiatric Patients in the Emergency Department,"" dated 07/2017, showed that:
- The hospital will maintain a Behavioral Assessment Team (BAT), Social Services, and/or Geriatric Wellness Unit Staff to assist the ED staff when a behavioral assessment is needed.
- The BAT or Social Services should be consulted to complete a behavioral assessment after the patient has been assessed by the provider and received medical clearance as determined by the physician.

3. Patient #22 was a [AGE] year old man (turned 63 during this series of visits) that presented three times to the Emergency Department (ED) by ambulance (2/23/17, 3/27/17, 3/28/17). On each visit the patient was agitated and had a bizarre presentation. He had a complex medical and psychiatric history that included partial vision loss in left eye, hypertension (high blood pressure), Hepatitis C (an infection of the liver), chronic pain, birth defect, depression (feelings of sadness that can affect how you think and act), bipolar disorder (mood swings that can result in extreme behavior changes from depression to emotional highs), anxiety (constant worry and/or fear that can affect actions), and schizophrenia (mental illness that can result in faulty thoughts or inappropriate actions). His last known inpatient psychiatric admission was for attempted suicide by medication overdose in June, 2016.

4. Visit 1

Record review of Patient #22's initial visit to the (ED) on 02/23/17 showed the patient arrived by ambulance to the ED at 6:59 PM.

The ED Registered Nurse (RN) Staff S documented that the Patient #22:
- Was brought in by Emergency Medical Services (EMS) after being called by patient's wife;
- Was paranoid (extreme distrust of others) and refused medications;
- Saw and heard things per wife;
- Stated that he was "under strong attack by an outside force";
- Was alert but confused.

ED Physician O documented on 02/23/17 at 7:50 PM that Patient #22:
- Was brought by EMS with complaint of increased paranoia and hallucinations (saw things that weren't there);
- Could not describe what he was seeing;
- Was not suicidal (thoughts of harm to self) or homicidal (thoughts of harm to others);
- Stated that he was under attack and was afraid of that;
- Was obsessive (can't control actions), paranoid and had visual hallucinations;
- Had a clinical impression of acute exacerbation (sudden onset of symptoms) of chronic schizophrenia , paranoia and visual hallucinations.

At 6:43 PM Staff O ordered blood tests and electrocardiogram (EKG- electrical tracing of heart activity) on Patient #22.

ED Physician O handed over care of Patient #22 to ED Physician G.

At 9:10 PM ED Physician G consulted by phone with Physician K, Psychiatrist, about Patient #22's care and documented that:
- Staff K reviewed Patient #22's record remotely (was not in the ED);
- Staff K believed that the patient should get an injection of paliperidone (a medication used to treat schizophrenia) and alprazolam tablet (medication used to treat anxiety);
- She had discussed this plan with the patient and his wife;
- The patient acted appropriately at this time.

At 9:21 PM Staff G wrote discharge orders which indicated that:
- The primary impression was an acute exacerbation of chronic schizophrenia with paranoia and hallucinations;
- The drug screen was positive for methamphetamine (typically an illegally manufactured drug that caused stimulation);
- The patient should follow up with his psychiatrist and advise his doctor of the injection that he received in the ED.

5. Visit 2

On 03/27/17 at 12:33 AM Patient #22 returned to the ED by ambulance with complaint of, "not doing well, feel like I am starting to lose control."

On 03/27/17 at 12:34 AM Staff R, ED RN, documented that Patient #22 appeared anxious, restless, apprehensive, agitated, and agitated movements.

On 03/27/17 ED Physician G documented that:
- She knew this patient from his last ED visit (02/23/17);
- He had similar symptoms and Staff K recommended an injection of paliperidone, a dose of alprazolam, and to follow up with his psychiatrist, the same medications ordered then were reordered on this visit;
- Patient stated that his thoughts were racing and he couldn't keep up with his thoughts;
- Patient stated he did not follow up with his psychiatrist;
- Patient stated he ran out of alprazolam;
- Patient can be discharged as soon as he has a responsible adult to pick him up and got the injection medication that was ordered;
- The patient did not follow up after the last visit so I do not trust that he will call his psychiatrist for an appointment today to get his shot.

ED Physician G ordered multiple blood tests, an electrocardiogram, urine analysis (breakdown of components in urine), urine drug screen (breakdown of narcotics or abused drugs in urine).

6. Visit 3

On 03/28/17 at 6:03 PM Patient #22 returned to the ED by ambulance with complaint of medication withdrawal/psychiatric behavior.

On 03/28/17 at 6:15 PM Staff S, ED RN, documented that Patient #22 was throwing himself side to side in the bed, resistive to care, shouting and moaning, appeared unkempt, speech unclear, agitated, and agitated movements.

On 03/28/17 at 6:50 PM Staff T, ED RN, documented that Patient #22:
- Was extremely agitated;
- Was screaming, "Just kill me";
- Was tachypnic (fast and deep breathing) , tachycardic (fast heart rate), hypertensive and diaphoretic (excessive sweating);
- Required the assistance of three RN's and security to keep patient still to insert an intravenous (IV- tube placed directly into vein for administration of medications and/or fluid)) line.

On 03/28/17 ED Physician L documented that Patient #22:
- Arrived to ED in much distress, moaning constantly, and in constant physical motion;
- Said he was reliving his past over and over;
- said he cannot control his movements;
- Said he has lost track of time;
- Was in this ED yesterday (03/27/17) for schizophrenia and psychiatry recommended an injection of paliperidone (this medication was administered yesterday based on the psychiatrist recommendation on 02/23/17- psychiatrist was not consulted yesterday).
- Had good resolution of his agitation and movement abnormality with medications.

At 7:00 PM care of Patient #22 was handed off from ED Physician L to ED Physician O.

At 9:10 PM ED Physician O documented that Patient #22 was much improved and wanted to go home.
At 9:12 PM ED Physician O entered discharge orders and a discharge diagnosis of "Ran out of Medication."
Patient was discharged to home.

None of these encounters resulted in a Behavioral Assessment Team (BAT) evaluation request by the ED physicians to further explore the patient's bizarre presentations.

During an interview on 07/20/17 at 9:05 AM Staff G, ED Medical Director, stated that:
- On the visit of 02/23/17 she called Physician K, Psychiatrist, because of the patient's symptoms and his history of a psychiatric admission in June, 2016;
- After Staff K reviewed the ED record he suggested an injection of medication, and a tablet for anxiety;
- She was on duty on 03/27/17 and when Patient #22 presented, she remembered the patient's previous visit and the psychiatrist's recommended treatment, so she ordered the same injection and tablet;
- She did not feel the patient needed a behavioral health assessment based on his symptoms;
- She stated that the ED physician was ultimately responsible for the patient disposition and the BAT evaluation might provide some additional information, but the ED physician did not necessarily always need that information.

During an interview on 07/20/17 at 9:25 AM Staff O, ED Physician, stated that he did not remember any specifics about either visit related to this patient. On the first visit the patient's care was turned over to ED Physician G. On the third visit care was turned over to him. He believed that, in general, the BAT evaluations were very accurate but that the patient disposition was the ED physician responsibility.

During an interview on 07/20/17 at 8:45 AM Staff L, ED Physician, stated that he did not remember any specifics about this patient but that he would always err on the side of patient safety.

During an interview on 07/20/17 at 9:35 AM Staff K, Psychiatrist, stated that upon review of Patient #22's ED records and the record of his previous admission (June 2016) he believed it would have been prudent to obtain a BAT assessment on the second or third visit to the ED. He stated that it may not have resulted in inpatient psychiatric admission but, based on the documentation, it appeared an assessment was indicated.

During an interview on 07/20/17 at 11:10 AM Staff H, ED RN, stated that the ED RN's were not qualified to determine what evaluations or interventions were indicated. The RN's would always advocate for patients but it was the ED physicians that would determine interventions and dispositions.

The hospital ED Physicians failed to recognize that an emergency medical (psychiatric) condition (EMC) may have existed when medical screening examinations (MSE) were insufficient to determine the cause of patients multiple and bizarre presentations. The facility had the capacity and capability to complete an MSE to determine if an EMC existed but failed to recognize that multiple presentations could represent a danger to this patient. The facility's failure to evaluate or treat the patient's condition after a presentation of aggressive behavior, uncontrolled thoughts, and bizarre actions could have placed this patient in danger.

7. Record review of Patient #21's ED record, dated 05/01/17 showed:
-The patient arrived in the ED per private vehicle on 05/01/17 at 12:36 PM.
-Staff B, Registered Nurse (RN), documented at 12:52 PM that the chief complaint was the need for a psychiatric evaluation as requested by the Division of Family Services (DFS), after the patient made snapchats (multimedia phone application used to message) that were depressing yesterday.
-Staff B, RN, documented at 12:52 PM that the patient was not suicidal or homicidal.
-Staff A, RN, documented at 1:31 PM that the patient was angry with another female student yesterday and was having problems with a place to stay so she posted some negative comments on snapchat; another student who saw the snapchats reported it to school administration.
-Staff A, RN, documented at 1:31 PM that the patient had a past history of mental health problems and of hospitalization for mental health problems.
-Staff P, ED physician, documented under history of present illness at 12:55 PM that the patient reported she was having a bad week and was more depressed than normal. The patient stated that she posted on snapchat she was not suicidal but if a car was coming she would not get out of the way. Patient denies suicidal thoughts and denies prior suicide attempt. Patient has difficulty with friends and living situation. ED physician (Staff P), documented under past history that the patient had a history of anxiety, depression, psychiatric problems, and suicide attempt. The patient reported a history of alcohol use and methamphetamine abuse.
-Patient discharged to home at 1:21 PM, with instructions to return if condition worsens, has increasing depression or thoughts of hurting herself or others. No follow up appointments documented.

During an interview on 07/20/17 at 10:00 AM, Staff B, RN, stated that the normal care process for a patient needing psychiatric evaluation was for the ED physician to complete a medical exam to clear the patient medically and then BAT or social services would be notified by ED staff to complete a behavioral assessment. Nursing would get orders from the physician to call BAT or social services prior to having ED staff call. Staff B, RN, stated that patients with the chief complaint of Patient #21 would normally have had a behavioral assessment by BAT or social services. Staff B, RN, stated she does not know why this patient did not get a behavioral assessment.

During an interview on 07/20/17 at 11:00 AM, Staff A, RN, stated that she doesn't really remember this patient and does not know why the patient did not have a behavioral assessment. Staff A, RN, stated that patients with the chief complaint of Patient #21 would normally have had a psychiatric evaluation by BAT or social services.

During an interview on 7/19/17 at 2:25 PM, Staff F, Director of ED, stated that the normal care process for a patient needing psychiatric evaluation was for the ED physician to complete a medical exam to clear the patient medically and then BAT or social services would be notified by ED staff to complete a behavioral assessment. Nursing would get orders from the physician to call BAT or social services prior to having ED staff call. Staff F stated that patients with the chief complaint of Patient #21 would normally have had a psychiatric evaluation by BAT or social services. Staff F stated she does not know why this patient did not get a behavioral assessment.

During an interview on 07/25/17 at 11:03 AM, Staff P, ED physician, stated that he felt this was a safe discharge because patient did not have any thoughts of suicide it was an anger issue only and that the patient did not have a psychiatric or medical emergency. The ED physician (Staff P) stated that the ED physicians in general only get BAT or social services involved to cover themselves when needed. The ED physician (Staff P) stated that he only does a drug test and alcohol level when the patient needs to be admitted to a psychiatric facility because the psychiatric facility requires it prior to admission. The ED physician (Staff P) stated that he felt the discharge of this patient was safe.

During an interview on 07/20/17 at 10:20 AM, Staff G, ED Medical Director, stated that after review of Patient #21's medical record she felt the discharge was safe because the patient had no prior suicide attempts and the patient was not reporting any suicide ideation at the time of this ED visit. Staff G, stated that physicians in the ED can do a psychiatric evaluation and that the BAT or social services were not always necessary but for Patient #21 the documentation of a behavioral assessment was not well documented by the ED physician (Staff P).

The facility failed to complete a medical screening examination, including a mental health evaluation, sufficient to determine the presence of a psychiatric emergency when they assessed Patient #21 with depression and discharged her to home.

8. Record review of Patient #19's ED record, dated 04/15/17 showed:
-The patient arrived in the ED per private vehicle with parents on 04/15/17 at 1:57 PM.
-The patient was a two year old female.
-Staff D, Registered Nurse (RN), documented at 2:00 PM that the chief complaint was the need for examination due to possible sexual assault.
-Staff G, ED physician, documented at 2:12 PM that mom brings child in for evaluation after picking child up at grandfathers house today where they spent the night; mom discovered a registered sex offender was staying at the grandfathers house as well. The patient's sibling (Patient #20) told the mother that they had to take off all of their clothing to go to bed.
-Staff G, ED physician, documented at 2:12 PM that she would do a medical exam and then contact a social worker who would assist with getting the patient set up for a sexual assault forensic exam (SAFE) (examination to collect evidence from sexual assault) elsewhere because there were no staff trained at this facility to complete this type of exam.
-The medical record of Patient #19 does not include an examination of the female genitalia area.
-Staff G, ED physician, documented at 2:12 PM that approximately five minutes after leaving Patient#19's room the father became angry because of the wait time and that he was leaving.
-Staff C, RN, documented at 2:35 that the physical assessment of the genitalia met standard of normal.
-Staff C, RN, documented at 3:13 PM that the father was angry because no examination had been completed yet and was leaving. The RN explained to the father that his daughter needed a SAFE exam which this facility does not do. The RN documented that the parents were also notified of this information prior to checking in to the ED.
-Staff C, RN, documented at 3:13 PM that a report to Child Protective Services (CPS) hotline was completed.
-Parents eloped with Patient #19 at 3:16 PM.

During an interview on 7/20/17 at 9:15 AM, Staff D, RN, stated that the normal process for minor (persons [AGE] and under) patients who come in for a sexual assault were given a medical exam by the physician and then arrangements were made to have a SAFE exam at another facility because no one was trained to complete a SAFE exam at this facility. The RN stated that once the patient was there they would usually not be allowed to leave, if an attempt was made security and the local police would be notified. The RN recalls the father being angry because an examination was not completed in a timely manner and his time was wasted. The RN stated that it was explained up front to the parents that a SAFE exam could not be done at this facility. The RN remembers following the parents with Patient #19 out to the parking lot trying to get them not to leave but did not call security or the local police.

During an interview on 7/20/17 at 9:25 AM, Staff C, RN, stated she did document that the genitalia met standard of normal but admits she did not do a visual exam of the genitalia. The RN states that an examination would not be done because it may be traumatic and patients with sexual assault were very sensitive. The RN states that the exam should be done by staff that were trained to do SAFE exams. The RN stated there was nothing suspicious noted with the parents or Patient #19 when she was working with them so she felt it was not necessary to try to prevent them from leaving the facility. The RN stated it was not her responsibility to stop them and that she could only do so much.

During an interview on 7/19/17 at 2:25 PM, Staff F, Director of ED, stated the normal process for any minor (persons [AGE] and under) patients who come in for a sexual assault were given a medical exam by the physician, which may or may not include a visual exam of the genitalia, and then arrangements were made to have a SAFE exam at another facility because no one was trained to complete a SAFE exam at this facility. Staff F stated that an examination of the genitalia area would only occur if the patient reported actual trauma to the genitalia. Staff F stated that once the patient was there they would usually not be allowed to leave, if an attempt was made security and the local police would be notified. Staff F stated sexual assault patients would usually only be allowed to transfer by law enforcement, CPS, or ambulance to another facility for the SAFE exam.

During an interview on 07/20/17 at 10:20 AM, Staff G, ED Physician and Medical Director of the ED, stated that she felt the elopement of Patient #19 was not of concern because the patient was not going back to a residence that was unsafe. Staff G stated that there was a custody battle between the grandparents and the parents which was why the parents brought Patient #19 to the facility.

The facility failed to complete a medical screening examination sufficient to determine the presence of an emergency medical condition when they assessed Patient #19 with possible sexual assault and allowed the patient to elope.

9. Record review of Patient #20's ED record, dated 04/15/17 showed:
-The patient arrived in the ED per private vehicle with parents on 04/15/17 at 1:57 PM.
-The patient was a four year old female.
-Staff D, Registered Nurse (RN), documented at 1:58 PM that the chief complaint was the need for examination due to possible sexual assault.
-Staff G, ED physician, documented at 2:12 PM that mom brings child in for evaluation after picking child up at grandfathers house today where they spent the night; mom discovered a registered sex offender was staying at the grandfathers house as well. Patient #20 told the mother that she had to take off all of her clothing to go to bed.
-Staff G, ED physician, documented at 2:12 PM that she would do a medical exam and then contact a social worker who would assist with getting the patient set up for a SAFE exam elsewhere because there were no staff trained at this facility to complete this type of exam.
-The medical record of Patient #20 does not include an examination of the female genitalia area.
-Staff G, ED physician, documented at 2:12 PM that approximately five minutes after leaving Patient #20's room the father became angry because of the wait time and that he was leaving.
-Staff C, RN, documented at 2:33 that the physical assessment of the genitalia met standard of normal.
-Staff C, RN, documented at 3:13 PM that the father was angry because no examination had been completed yet and was leaving. The RN explained to the father that his daughter needed a SAFE exam which this facility does not do. The RN documented that the parents were also notified of this information prior to checking in to the ED.
-Staff C, RN, documented at 3:13 PM that a report to Child Protective Services (CPS) hotline was completed.
-Parents eloped with Patient #20 at 3:16 PM.

During an interview on 7/20/17 at 9:15 AM, Staff D, RN, stated that the normal process for minor (persons [AGE] and under) patients who come in for a sexual assault were given a medical exam by the physician and then arrangements were made to have a SAFE exam at another facility because no one was trained to complete a SAFE exam at this facility. The RN stated that once the patient was there they would usually not be allowed to leave, if an attempt was made security and the local police would be notified. The RN recalls the father being angry because an examination was not completed in a timely manner and his time was wasted. The RN stated that it was explained up front to the parents that a SAFE exam could not be done at this facility. The RN remembers following the parents with Patient #20 out to the parking lot trying to get them not to leave but did not call security or the local police.

During an interview on 7/20/17 at 9:25 AM, Staff C, RN, stated she did document that the genitalia met standard of normal but admits she did not do a visual exam of the genitalia. The RN states that an examination would not be done because it may be traumatic and patients with sexual assault were very sensitive. The RN states that the exam should be done by staff that were trained to do SAFE exams. The RN stated there was nothing suspicious noted with the parents or Patient #20 when she was working with them so she felt it was not necessary to try to prevent them from leaving the facility. The RN stated it was not her responsibility to stop them and that she could only do so much.

During an interview on 7/19/17 at 2:25 PM, Staff F, Director of ED, stated the normal process for any minor (persons [AGE] and under) patients who come in for a sexual assault were given a medical exam by the physician, which may or may not include a visual exam of the genitalia, and then arrangements were made to have a SAFE exam at another facility because no one was trained to complete a SAFE exam at this facility. Staff F stated that an examination of the genitalia area would only occur if the patient reported actual trauma to the genitalia. Staff F stated that once the patient was there they would usually not be allowed to leave, if an attempt was made security and the local police would be notified. Staff F stated sexual assault patients would usually only be allowed to transfer by law enforcement, CPS, or ambulance to another facility for the SAFE exam.

During an interview on 07/20/17 at 10:20 AM, Staff G, ED Physician and Medical Director of the ED, stated that she felt the elopement of Patient #20 was not of concern because the patient was not going back to a residence that was unsafe. Staff G stated that there was a custody battle between the grandparents and the parents which was why the parents brought Patient #20 to the facility.

The facility failed to complete a medical screening examination sufficient to determine the presence of an emergency medical condition when they assessed Patient #20 with possible sexual assault and allowed the patient to elope.