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CHI HEALTH IMMANUEL 6901 NORTH 72ND ST OMAHA, NE 68122 Jan. 9, 2017
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on medical record review, review of facility Medical Screening Examination (MSE) policy and provider interviews the facility failed to ensure 1 of 20 sampled patients (Patient 10) received an adequate MSE to determine if the patient had an Emergency Medical Condition (EMC), This failure placed the patient at risk of harm. The patient was discharged with a potential EMC. Findings are:

A. Review of facility policy titled "Emergency Medical Treatment and Active Labor Act" last revised 11/2016 identified that "An appropriate MSE will be provided within the capabilities of the department, and ancillary services routinely available to the department to determine whether or not an EMC exits." The policy identifies the Qualified Medical Professional (QMP) "provides the medical screening examination and treatment deemed necessary to stabilize the patient." The policy defined an EMC as a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain such that the absence of immediate attention could reasonably expect to place the health of the individual ... in serious jeopardy ... serious impairment to bodily functions ... serious dysfunction of any bodily organ or part ...

The policy and the hospital Medical Staff Rules and Regulations last revised 10/15/15 identify that the MSE is done to examine the patient for existence of an EMC. The QMP "shall mean a licensed independent practitioner (LIP) that can provide the medical screening examination without assistance from another LIP. A QMP may be a MD, DO, Nurse Practitioner (NP), Physician Assistant (PA) or Registered Nurse (RN) with additional training in obstetrical services. LMHP may be a QMP when performing the psychosocial risk assessment in accordance with the facility EMTALA policy.

B. Review of the "Hospital/CAH Database Worksheet" completed by the hospital during the onsite survey on January 4, 2017 indicated the hospital's capabilities included a 20 bed psychiatric unit, alcohol and/or drug detoxification services, emergency psychiatric services including those for children/adolescents, adults and seniors.

C. Review of Patient 10's electronic medical record on 1/5/17 revealed the patient came to the Emergency Department at 8:11 PM on 1/1/17 by private vehicle accompanied by friend/family. Vital signs were taken by the Triage RN at 8:17 PM. BP was elevated at 156/100, Temperature was 99.1 Fahrenheit, Pulse was 98 and Respirations 16. Oxygen saturation on room air was normal at 98 %. The MSE was performed Physician Assistant PA "A" and Licensed Mental Health Practitioner LMHP " B".

PA A initiated the exam at 8:20 PM. Under section titled "Chief Complaint" PA A documented that the patient presented for an examination by psychiatry. The patient had been to a local alcohol/drug treatment center for detoxication and it was unable to provide care due to the patient's use of benzodiazepines. Benzodiazepines require a long slow taper under licensed medical supervision.

Further documentation showed that the patient abused methamphetamine, cocaine, marijuana and prescription drugs. The patient told the PA that she used heroin, methamphetamine and cocaine daily. The patient reported the last use was yesterday. The patient reported taking prescribed Xanax (a benzodiazepine ) 2 mg (milligram) orally 3 times a day. The PA documented the patient denied being suicidal, homicidal or hallucinating, or having any physical concerns. The PA documented the patient was not nervous/agitated or anxious. Medical history included adjustment insomnia, unsafe sexual practices, fatigue, limb pain, sacroiliitis, transsexualism, and anxiety. Surgical history included intersex surgery and mammaplasty.

The patient's current medications included: Xanax; Tegretol (used to treat seizures; nerve pain and bipolar disorder); Chantix (smoking cessation medication): Klonopin (another benzodiazepine for anxiety/panic disorder); Catapress (used to treat high blood pressure, anxiety disorder, withdrawal from alcohol or opiods); Prednisolone (a steroid); Minipress (used to treat high blood pressure) Proventil inhaler (treats asthma), Suboxone 8 - 2mg Film (medication used to treat opiod addiction; Zanaflex (a short acting muscle relaxer); and Trazodone (an antidepressant drug which is also used for anxiety disorder and insomnia). Further documentation showed the patient had a family history of suicide/attempt. The patient denied alcohol use and admitted to IV drug use and admitted to injecting Fentanyl (an opiod medication) and abusing prescription drugs.

PA A futher noted that the patient was oriented to person, place and time, appeared well developed and well nourished with a non-toxic appearance. Under the assessment titled "Psychiatric" the PA documented the patient had a "normal mood and affect." Speech and behavior was normal. The patient was not actively hallucinating. Cognition and memory were noted to be normal. A urine drug screen was ordered but the patient was not able to provide a specimen so it was not completed. No other labs were ordered.

The on call Licensed Mental Health Professional (LMHP) B conducted a psychosocial risk assessment. LMHP B noted the patient was disheveled, reported she was homeless and on drugs. The patient came because she "had no where to go, and was trying to get off drugs." The patient reported not using drugs within the last 24 hours and has not used heroin in the last 5/6 days. The LMHP documented the patient was "not having withdrawals at the time of the assessment but reported that she had been going through withdrawals", patient states that she is not a danger to herself or others, and has not thought about hurting herself.

Further documentation showed that the patient reported that since using drugs she has had hallucinations but that it does not happen all the time and when it does it is scarey. The patient confirmed using Methamphetamine for several years along with benzodiazepines and heroin. The patient has no family support secondary to drug use. The patient denied having legal problems, being a victim or victimizing anyone. The patient denied suicidal or homicidal ideation but was positive for auditory and visual hallucinations. The patient spoke fluently and was free of delusions.

The patient's depression score was 10 out of 10 (10 being severe) as well as anxiety. The patient reported hopelessness as a 3 out of 10. The patient was concerned about her housing issues and drug use. The LMHP discussed the assessment with PA A. It was determined the patient would be discharged with a referral to [Facility C], a local medically supervised alcohol and drug treatment center. The LMHP confirmed the facility would have a bed for the patient in the morning. The bed was not available at the time of discharge. The patient was given discharge instructions and information regarding inpatient/outpatient drug treatment services. The patient was discharged at 9:38 PM.

The medical record did not contain evidence that patient # 10 received a medical screening examination within the hospital's capabilities and capacity. The patient presented to the ED from a detoxification facility that could not help her because of her chronic benzodiazepine use. The patient had an abnormal blood pressure reading of 156/100 that was not repeated. The medical record did not contain evidence that staff determined the patient's history of a coexisting mental illness, timing for onset of symptoms of withdrawal (life threatening symptoms when a chemically dependent person suddenly stops taking the drugs), or risks associated with severe depression rated 10 out of 10 in a chemically dependent / addicted individual who has suddenly stopped taking drugs.

Review of the patient # 10's medical record history found the patient had been seen on 12/21/16 for a "mental health evaluation and was admitted for a "brief psychotic disorder" in one of CHI Health Immanuel's affiliated hospitals.

D. Interview with PA A on 1/6/16 at 9:15 AM revealed the patient "did not seem to be under the influence" and seemed mentally clear. The patient reported taking the Xanax as prescribed and that it was prescribed by "her psychiatrist." The PA stated that the main concern for the patient was a desire to detox. The PA recalled discussing the patient with the LMHP after the mental health exam. The LMHP "told me the patient did not meet admission Criteria for inpatient psychiatry." PA A stated that if a patient is withdrawing while in the ED, we provide medications and fluids and admit them if they are unstable. The plan for patient # 10 was "referral to [Name of Facility C]." The LMHP verified that a bed was available in the morning and that Facility C could do benzodiazepine withdrawal.

E. In an interview on 1/6/16 at 11:50 AM, LMHP B stated the patient told her that she was not "experiencing any withdrawals." LMHP B stated that patient # 10's demeanor was slightly odd but did not appear to be high or impaired. The patient reported drug use for a number of years and wanted help to stop using. The previous shelter was unable to help. LMHP B confirmed the hospital had available inpatient psychiatric beds when patient # 10 presented to the ED.

F. In an interview on 1/6/17 at 2:00 PM, an annonymous individual indicated he picked patient # 10 up from the ED after discharge. The individual stated patient # 10 was delusional, paranoid, hearing voices and seeing people who were not there at the time of discharge from the ED on 1/1/17.