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MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 April 10, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy and procedure review, closed medical record review, and staff and physician interviews, the hospital staff failed to comply with 42 CFR 489.24.

The findings include:

1. The hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize 1 of 21 patients with a mental health emergent medical condition (Patient #47).

~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure review, closed medical record review, and staff and physician interviews, the hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize 1 of 21 patients with a mental health emergent medical condition (Patient #47).

The findings include:

Review of the hospital's policy, "Emergency Medical Treatment and Active Labor (sic) Act (EMTALA)", revised 02/26/2014, revealed, "(Name of Hospital) accepts clinically appropriate patients within the system's capability, resources and capacity. ...(Name of Hospital) will adopt and enforce policies and procedures to ensure compliance of all hospitals, their staffs, and medical staffs with the requirements of the...EMTALA regulations. ...DEFINITIONS: ...D. 'Emergency Medical Condition': 1. 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 to expected to result in" a. Placing the health of the individual...in serious jeopardy...G. 'To stabilize or stabilized: ' 1. With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure,within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient...3. The emergency medical condition has resolved. H. 'Stable for discharge:' ...2. With respect to an individual with a psychiatric condition, a physician or QMP (qualified medical provider) in consultation with a physician determines that the patient is protected and prevented from injury himself/herself or others until the transfer is concluded. ...EMTALA PROVISIONS OVERVIEW ...STABILIZATION: A. When the hospital determines that an individual has an EMC (emergency medical condition), and the EMC is appropriate and within the capacity and capability of the hospital facilities and qualified personnel, the individual experiencing an EMC must be stabilized prior to transfer or discharge...'Stabilization' for discharge is achieved when the patient's EMC has resolved to the point within reasonable clinical confidence, where the patient's continued care, where appropriate, including further diagnostic work-up and/or treatment, could be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with discharge instructions. ...1. For psychiatric patients, ... 'stable to discharge' is achieved when the patient is no longer an imminent threat to self or others within reasonable clinical confidence
...".

Closed DED record of Patient #47 revealed a [AGE] year old male who presented to the hospital's DED on 03/12/2014 via EMS (Emergency Management Services) at 0109 on a voluntary basis with chief complaint of intoxication and suicidal ideation. Record review revealed Patient #47 requested detoxification. Record review revealed Patient #47 was admitted to the hospital's behavioral health unit on 03/14/2014 at 2225. Review of the discharge summary dictated by a psychiatrist revealed the patient was non-compliant with medication and had quit taking Lithium a year ago. Record review revealed the patient was started on Tegratol (mood stabilizing medication) on admission and had a therapeutic level of 6.4 on 03/20/2014. Further review revealed the patient was homeless, a shelter was found for him and gas money was obtained for the patient to travel to Marion (36 miles). Further review revealed the patient was no longer a danger to himself or others and was discharged at 1015 on 03/20/2014.

Further record review of Patient #47 revealed the patient returned ambulatory to the hospital's DED on 03/20/2014 at 1642 (6 hours, 27 minutes after discharge) with chief complaint of suicidal ideation. Record review revealed the patient was triaged at 1715 by Registered Nurse (RN) #1 and was assigned an ESI level of 2. Further review revealed Patient #47 was medically screened by a family nurse practitioner (FNP #1) at 1831. Review of FNP#1's dictated note revealed, " ...History of Present Illness 52 yo (year old) male with forced, rapid speech who is here tonight after discharge today from our facility. The patient tells me that his discharge plan included follow up care and he was going to live in Marion at a facility that would be able to help him 'get back on his feet ' . The patient tells me that he left our facility and went to 'get my wallet and my keys'. When asked where they had been left he tells me 'at Helen's bridge'. The patient reports that he found his wallet without difficulty, but he could not find his keys. He tells me that this was so traumatic to him that he began feeling overwhelmed. He tells me that 'everything I own is in my truck'. He tells me that he tried to get his 'case worker to help me', but he could not afford a locksmith and so when he found that he was not going to get into his truck he began thinking about suicide. The patient tells me that he went 'to the top of 445 Biltmore, but someone waved at me so I did not jump- I did not want to make a mess' ... He decided to come here. When asked if he was still suicidal, he tells me yes. When asked what he thinks would help these suicidal thoughts, the patient tells me 'if someone would get me in to my truck' . No physical complaints. Recent hx (history of CVA (cerebrovascular accident). Review of Systems Other significant review of systems. The systems are reviewed and negative with exceptions as recorded in present illness. Past Medical/Family/Social History ...Social History Alcohol: The patient has a history of alcohol abuse. He reports that he has maintained his sobriety from detox. ...Occupation: Unemployed, Family/Social Situation: Homeless Physical Examination ... Behavior: Cooperative. The patient is repetitive with forced, rapid speech. ...Medical Decision Making Differential Diagnosis Anxiety disorder, Suicidal Risk... " . Further review revealed a urine drug screen was positive for barbiturates. Further review of FNP#1's medical screening exam revealed, "...I feel strongly that the patient's homelessness is contributing to his issues. He was happy with the discharge plan from earlier, but tells me that without his truck and belongings, he cannot go to Marion. He now feels hopeless and overwhelmed. He reports a near suicide attempt earlier. We have monitored the patient during the ER (emergency room ) course and he remains stable. After speaking with the psychiatric intake team it is felt that he would benefit from further evaluation. His belongings have been secured and he has been under direct monitor observation. ... " . Further review reveled the patient's care was transferred to the psychiatric intake team for further evaluation.

Further record review of Patient #47 revealed an evaluation was ordered and completed by a licensed clinical social worker (LCSW#1) from the hospital's behavioral health unit on 03/20/2014 at 2252. Review of the LCSW #1's dictated assessment revealed, "...Pt is a 52 yo DWM (divorced, white male) diagnosed with Bipolar I, mixed and Alcohol dependency. He is suspected of throwing his keys and wallet into the woods when he ran out of gas. He does present with rapid and pressured speech, loose association and ruminations around his truck keys. He is a poor historian describing how he went to Myrtle Beach for vacation and a job two weeks ago but then hoped to go to Augusta and find work at the Master's golf tournament and didn't, so he returned to Asheville. He shared info (information) about feeling he was having a heart attack or stroke while in Myrtle Beach but then found it was anxiety...He was discharged from Copestone (Hospital's behavioral health unit) today following an admission on 03/14. He had a previous admission on 10/2-10/8/13. Directed at getting money from his parents per the medical record. Suspected of malingering at that time yet displaying symptoms of mania that stabilized. Pt presents manic with rapid speech and a disheveled appearance. He states that he hasn't worked for some time and but previously sold real estate and was a gardener. When he left Copestone today, he was to go to a shelter in Marion, the John Thompson Ctr but didn't get there due to his 'freak out' when he threw his keys and wallet into the woods. He states that he then was able to find his wallet but not his keys so he couldn't go to Marion and walked to the ED to ask for help. He states that he had his 8th dose of Tegratol today as he no longer wants to take lithium which he took for 30 years. He reports drinking 8 beers two weeks ago and none since. His truck remains in the parking lot of October Road with his belongings. Pt reports his first hospitalization at [AGE] yo in Highland Hospital in Asheville with multiple detoxes and treatment throughout the years. Pt wants to go into the hospital for stabilization. He denies using any other drugs but alcohol. He denies SI (suicidal ideation)/HI (homicidal ideation/AVH (auditory-visual hallucinations) though he earlier reported attempting to jump off a building near October Road. Pt states he would 'just like to get some help to get to the John Thompson Ctr in Marion'. Pt denies any support system in the area in the way of family or friends. ...Recommendations: Recommend telepsych with possible observation and discharge in AM if stable mood. (FNP #1) agrees. ...Pt cooperative and resting... " .

Further record review revealed Patient #47 was transferred to the hospital's PEA (psychiatric evaluation area) on 03/20/2014 at 0300. Further review revealed a progress note dictated by Psychiatrist #1 on 03/21/2014, time unknown, electronically signed on 03/21/2014 at 1551. Review revealed, "Interval History: The patient was seen and the chart reviewed. The patient apparently was just discharged from Copestone the day prior to presentation. His car ran out of gas and for unknown reasons he threw his keys into the woods. He now cannot find his keys and all his belongings are inside the car. The patient was very clear with me that what he was looking for was a locksmith or someone to help him get into his car. He adamantly denied any thoughts of self-harm and said 'I just want to get in my car and go to my shelter in Marion'. I explained to the patient that a hospital is not a place for getting someone to make keys. The patient understood but was very focused on someone findings him a way to get into the car. The patient ultimately requested discharge and said that he would find a way to get someone to help him to get into his car. We did contact his shelter and he still has been waiting for them. He continued to deny any thoughts of self-harm. Review of Systems Constitutional: Negative. Gastrointestinal: Negative. Neurologic: No tremor. Vital Signs (last 24 hrs) Last Charted Temp 97.7 Heart Rate 94 Resp (Respiratory) Rate 20 SBP (Systolic Blood Pressure) 110 DBP (Diastolic Blood Pressure) 83 Sp02 (Oxygen Saturation) 99 Psych Mental Status Exam: Appearance: Normal. Musculoskeletal: No abnormality. Gait and Station: No abnormality. Behavior: Cooperative. Speech: No abnormalities. Mood: Euthymic. Affect: Full range of affect. Thought Content: No abnormality. No suicidal ideation. No homicidal ideation. Perceptual Disturbances: No hallucinations/illusions. Thought Process: Linear, Organized. Level of Intelligence: Average. Sensorium/Concentration: Normal. Orientation: Oriented x 4. Abstraction: Appropriate. Language: No abnormality. Memory: Intact. Fund of Knowledge: Appropriate for education and socioeconomic status. Insight: Lack of awareness of problems, mild impairment. Judgment: Mild impairment. ...Impression and Plan [AGE] year-old Caucasian male with a long history of bipolar disorder who presented one day after discharge from Copestone upset because he had lost his keys. He did initially present as manic and suicidal per the record but on my evaluation is quite linear and organized, adamantly denies any thoughts of self-harm. He is quite open about the fact that he came to the hospital to find someone who would assist or pay for him to get a new daily (sic) key for his car. When told that we could not do this for him he did request discharge. The patient is psychiatric stable for discharge. Diagnosis: Bipolar disorder, type I, mixed. Alcohol dependence. Tegrotol 200 mg po BID Disposition: The patient is very clear that he came to the hospital in order to get assistance with getting into his car. On my evaluation he adamantly denies any thoughts of self-harm. He still has his other medications on him. He still has the shelter bed available for him. He does not meet inpatient criteria and is psychiatric stable for discharge " . Further review revealed an order by Psychiatrist #1 dated 03/21/2014 at 1228 ( 9 hours, 28 minutes after admission for suicidal ideation) for Patient #47 to be discharged .

Further record review revealed a dictated note by a Licensed Clinical Social Worker (LCSW#2) on 03/21/2014 at 1119. Review of the note revealed, "...spoke with pt about options and how to best assist him in getting to the Marion shelter. Pt was drinking coffee and watching TV both times PC (professional counselor) spoke with him. PC recommended that pt call some locksmiths...Pt reported that he had already done that and that he just wanted to be dc'd (discharged ). Pt tried to speak with security about possibilities about getting a key made but they would not speak with him. PC recommended that pt be transported back to his vehicle to look for the keys again, but he wants to go on foot up to MMH (Hospital) so he can talk to security there as he is sure that one of them knows someone that can help him. (Psychiatrist #1) states that he is OK with pt being dc/d on foot. Pt did get mildly agitated about getting out quickly after he was informed that a locksmith was not being funded by the hospital " .

Further record review revealed an assessment completed by RN #2 on 03/21/2014 at 0817. Review revealed documentation by RN #2 that Patient #47 was not having suicidal ideations. Further review revealed the patient was discharged at 1301. Review of the written discharge instructions provided to the patient included to go to the McDowell Mission in Marion and telephone numbers for mobile crisis and suicide prevention hotlines. Further review revealed the patient was discharged with Tegratol and Thiamine prescriptions.

Interview on 04/09/2014 at 1145 with RN #1 revealed she triaged Patient #47 in the hospital's DED on 03/20/2014 at 1715. Interview revealed, "He was suicidal. He told me he had a plan. I didn't press him for information or the details of the plan. A behavioral health evaluation was done in the ED".

Interview on 04/09/2014 at 1400 with LCSW #1 revealed she met with Patient #47 in the hospital's DED on 03/20/2014. Interview revealed, "He was very polite, friendly and appreciative of the services he was getting. He was slightly manic. He needed assistance with a key for his truck. Based on my interaction with him, I felt like he needed a full mental health evaluation. I consulted with (FNP#1). We collaborated and decided he needed a full mental health evaluation. She medically cleared him and he was transferred to the PEA (psychiatric evaluation area). His care was transferred to the psych intake department. I asked him if he was suicidal. He said, 'no, I'm fine. I just need my key'. He was very vague about the key". Interview further revealed, "I found out he had jumped about 6:00 (pm) on 03/21/2014".

Interview on 04/09/2014 at 1500 with FNP#1 revealed she remembered Patient #47. Interview revealed, "I completed his screening exam when he came back into the ED that day. I said he was feeling depressed and that he had contemplated suicide that day". Interview further revealed the FNP ordered a behavioral health evaluation based on standing orders and his previous diagnosis.

Interview on 04/09/2014 at 1300 with Psychiatrist #1 revealed he made rounds on the PEA the morning of 03/20/2014. Interview revealed Patient #47 was "calm and organized. He was focused on the issue with his keys". Further interview revealed, " he denied wanting to hurt himself. He wanted help to get his keys. I told him we would do all we could to help him. We had found him a men's shelter in Marion the day before. He said he was starting his new life in Marion. We offered him transportation to the shelter in Marion. He would have none of that. His plan was to get a locksmith to get his car. He left with the yellow pages out of the phone book with locksmiths in the area". Interview further revealed, "He didn't meet criteria for IVC (involuntary commitment)". Interview further revealed, "I got a call from our practice manager about 4:30 (pm) on the 21st. She told me what had happened, that he had jumped from the parking deck and was dead. I have reviewed his records. I don't know anything else I could have done. I'm trying not to beat myself up...it's just sad". .

Interview on 04/09/2014 at 1330 with RN #2 revealed she was Patient #47's primary nurse on 03/21/2014 beginning at 0700. Interview revealed, "He told me he was embarrassed to be back. He told me a lengthy story about how he couldn't find his car keys. He said he just needed help to get his keys". Further interview revealed, "I asked him was he suicidal or homicidal and he said 'no, just needed help to get to Marion'. The Social Worker offered him a cab voucher to get to Marion and even offered to help get his belongings from the car. He said, 'no', he needed the vehicle. He said he phoned a friend and was able to get $50 to have the car rekeyed. He was happy about that". Interview further revealed, "I discharged him after lunch. We went over his discharge papers. He appeared hopeful. I don't know anything we could have done differently".

Review of the local county's rescue squad report dated 03/21/2014 with Patient #47's name documented in the space for patient information revealed the rescue squad was dispatched at 1716 for routine body transport. Review revealed, "arrived on scene to find APD (Asheville Police Department), APD Forensics and detectives on scene. Pt was found on ground beneath four story parking deck. Pt had been witnessed jumping from parking deck at 16:10 (3 hours, 9 minutes after discharge) according to APD. Pt sustained severe trauma to head, neck, extremities and internal injury...transported to morgue...".

Consequently, Patient #47 presented to the Hospital's DED on 03/14/2014 with suicidal ideation, was admitted to the inpatient psychiatric unit, discharged on [DATE] at 1015 and returned to the DED on 03/20/2014 at 1642 (6 hours, 27 minutes after discharge), was placed in the psychiatric area of the DED for observation and further evaluation, was discharged on [DATE] at 1301( 9 hours, 28 minutes after admission for suicidal ideation) and committed suicide around 1610 (3 hours, 9 minutes after discharge).

NC 572 and NC 349