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RUTHERFORD REGIONAL MEDICAL CENTER 288 SOUTH RIDGECREST AVE RUTHERFORDTON, NC 28139 July 22, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy review, medical record review, and staff interviews the hospital failed to comply with 42 CFR 489.20 and 489.24.

Findings include:

The hospital's Dedicated Emergency Department (DED) failed to provide further medical examination and treatment as required to stabilize the psychiatric emergency medical condition for 1 of 25 sampled DED patients (#25) who presented to the hospital's DED for evaluation and treatment.

~ Cross refer to 489.24(r) and 489.24(c) Necessary Stabilizing Treatment- Tag A 2407.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, closed medical record reviews, Hospital Daily Security Reports, and Occurrence Reports and staff interviews, the hospital failed to provide further medical examination and treatment as required to stabilize the psychiatric emergency medical condition for 1 of 25 sampled DED patient (# 25) who presented to the hospital's DED for evaluation and treatment.

Findings include:

Review on 07/22/2016 of the hospital's "Commit, D-50-ED-30" policy effective 03/1976, approved and revised 07/2016 revealed, "POLICY: 1. The emergency department staff will assess individuals presenting to the emergency department with signs/symptoms of [DIAGNOSES REDACTED]. Commitment when appropriate based on individual patient care needs ...7. When commitment is appropriate for patient care, the following process will be followed. PROCESS: I. Involuntary Commitment ... B. When the physician is the petitioner: 1. Physician will complete the Affidavit and Petition for Involuntary Commitment Form AOC-SP-300. A designated employee who is a notary will notarize the form. 2. The commitment process starts as soon as the provider verbally orders the process to begin. C. The original and three copies of Affidavit and Petition for Involuntary Commitment Form AOC-SP-300 will be signed by the physician. D. After all four copies of Affidavit and Petition for Involuntary Commitment Form AOC-SP-300 are completed; these copies must be taken to the Magistrate on Duty. a. Forms will be taken to the courthouse during the hours of 8 a.m. to 5 p.m. b. Forms will be taken to the Magistrate located at the Rutherford County Jail after 5 p.m. E. After the forms are taken to the magistrate, the magistrate will contact the _______ County Sheriff's Department. F. After notification, the sheriff ' s department will transport the patient to the appropriate facility (after EMTALA/COBRA forms completed) or to the (Hospital A) Psychiatric Center..."


A review of the hospital's "Emergency Medical Treatment and Labor ACT (EMTALA), H-50-90" effective 02/2013 revealed in part, "...PROCEDURE:...2. STABILIZATION: A. Where the hospital determines that an individual has an EMC, when appropriate and within the capacity and capability of the hospital facilities and qualified personnel, the individual experiencing an EMC must be stabilized prior to ....discharge...C. "Stabilization " for discharge is achieved when the patients EMC has resolved to the point within reasonable clinical confidence, where the patients 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.




Review on 07/22/2016 of the hospital's "Copy of Discharges Against Medical Advice, (AMA), D-50-PC217" policy effective 07/2016 revealed, "POLICY: It is the policy of the Emergency Services to release from the program any legally competent, voluntary patient upon their request. When it is clinically indicated to continue treatment and petition for discharge persists, the patient will be discharged AMA. Should the patient pose a substantial danger to self or others, involuntary commitment procedures will be initiated....PROCEDURE:...In the event that a patient openly expresses their intent to leave or desire to leave, an identified staff will meet with the patient immediately to explore with the patient concerns jeopardizing ongoing and needed treatment. Additionally, measures to be implemented include,A [sic] hospital occurrence report will be completed and forwarded to hospital administration, contact the Attending Practitioner for intervention...An individual who has been voluntarily admitted to a 24 hour facility may be held for 72 hours after his written application for discharge has been submitted. If the patient is determined to be an imminent danger to self or others, involuntary commitment procedures will be initiated according to North Carolina Mental Health, Developmental Disabilities and Substance Abuse Laws 122C-212C....All interventions with rationale will be documented in the clinical record. ..."

Review on 07/22/2016 of the hospital's "Suicide/Homicide Screening and Precautions, D-50-A37" policy last revised 06/2015 revealed, "POLICY: ...All patients who are determined to be a Suicide or Homicide risk will be placed on Suicide/Homicide Precautions. ... PROCESS: I. Screening A. Patients who present to the ED for treatment or hospital admission will be screened and assessed by a RN (Registered Nurse) for Suicide/Homicide risk. ... C. Screening questions are utilized to determine if the patient is homicidal or suicidal and if patient is suicidal or homicidal the Precaution Level needed is determined by further questions. Question One: Have you had thoughts of hurting or killing yourself or others over the past week? Question Two: Do you have a plan to hurt or kill yourself or others now? Describe the plan, [sic] Question Three: Do you have any intent to act on this plan? If patient answers YES to any questions, stay with the patient and notify charge nurse. ...Initiate Suicide/Homicide Precautions including discussing with medical staff the needed level of observation in order to maintain safety. D. If patients are identified at risk by the RN: ...ED patient manifesting behavioral health issues and needs will be assessed by the ED physician/provider who will determine and document the patient's risk for Suicide/Homicide and the need for Precautions. The physician will order or not order Precautions based on his/her determination and the reason for visit; e.g. Suicidal thoughts, developed plan, an attempt, or deliberate OD (overdose).... A ED patient identified as being suicidal/homicidal will be assessed by a qualified Behavioral Health RN or Social Worker following patient being deemed medically clear. The Emergency Department physician/provider may consult the Behavioral Health physician/provider at anytime [sic]. Inpatients manifesting behavioral mental health issues and needs will be assessed by the Attending Physician/Provider who will determine and document the patient's risk for Suicide or Homicide Precautions. The physician/provider will order or not order Suicide/Homicide Precautions based on his/her determination and the reason for visit; e.g. Suicidal thoughts, developed Suicide/Homicide plan, an attempt, or deliberate OD. The attending physician may consult the Behavioral Health physician/provider as needed. ... II. Suicide/Homicide Precaution Orders A. An order for Suicide/Homicide precautions will be obtained from the ER doctor and/or attending physician. Suicide/Homicide precautions may be instituted prior to securing a written order as deemed necessary by the primary nurse. The order will be as soon as practical. B. Suicide/Homicide Orders-Precaution are As [sic] follows: Level 1: Every 15 Minute Observation: ... Level 2: Visual Observation Patient is at high risk and high danger for suicide/homicide Patient Behavior may demonstrate: - verbalizing intent to harm self or others - vague or not viable plan communicated ... - poor impulse control - poor insight related to safety needs - communicating thoughts to elope without efforts to elope. ... Nursing Intervention: Visual line of sight of patient either in person or on a video monitor twenty-four (24) hours a day, without interruption. The assigned qualified sitter *must maintain the line of sight of the patient at all times, ...Sitter may observe more multiple patients at one time. Patient wears only hospital gowns or scrubs. ... 1:1 staff accompaniment for any medically necessary off unit activity such as tests or procedures."

Closed DED review, on 07/22/2016, for Pt # 25 revealed a [AGE]-year-old male presented voluntarily to Hospital A via private vehicle to the hospital's DED (Dedicated Emergency Department) on 04/25/2016 at 2150 (Visit #1). Review of "ED Activity" revealed the patient presented with "self-inflicted lacerations to the left forearm." Review of Triage documentation revealed the "ED Initial Triage" was performed at 2153. Review revealed vital signs were assessed as Temperature (T) 97.9 degrees Fahrenheit, Pulse (P) 98, Respirations (R) 20, Oxygen Saturation (SPO2) 98% on room air, Blood Pressure (BP)161/95 (United States National Library of Medicine BP normal 90/60-120/80) at 2154. Review revealed the patient was placed on a cardiac monitor with a frequency of "Q60M" (every 60 minutes) Vital Signs. Review revealed a "Suicide/Homicide Risk Screen with instruction as follows: *If yes to last question immediate intervention required. *Stay with patient. *Patient must be 1:1 with CPR (Cardiopulmonary resuscitation) trained staff. *Notify Charge Nurse and ADON (Assistant Director of Nursing)!" Review revealed " Have you had thoughts of hurting or killing yourself or others over the past week", "Do you have a plan to hurt or kill yourself or others?", and "Do you intend to act on this plan?" Review revealed Pt # 25 answered yes to all three questions. Review of the assessment revealed "Description of Symptoms - Self Inflicted Lacerations to Left Forearm. States he will kill himself if he leaves." Review revealed the Chief Complaint was "Psych Eval" (Psychiatric Evaluation). Review revealed the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe) and was placed on 1:1 Safety Precaution (constant staff presence and supervision) and moved to treatment room #7 ED dedicated "safe room" (room where potentially harmful objects have been removed for the safety of patient(s) and staff). Review revealed (Sitter #1) was assigned to maintain constant, 1:1 monitoring of the patient. Review revealed a "Psychiatric Assessment" was conducted by RN #2, which included, "Psychiatric Assessment: History, No; Previous suicide attempt, Stabbing/Cutting; History of Substance Use, Alcohol; Substance Use, Marijuana. Competency: Thought Process, Intact... Impulse Control Description: Poor; Sleep Symptoms: Insomnia (difficulty sleeping) ...Behavior Assessment: Patient Behavior, Cooperative, Anxious; Mood Description, Depressed, Anxious; Affect (individual's actions and physical appearance in relation to current circumstances) Description, Depressed, Anxious ...Precautions, Safety Precautions Implemented, Yes." Review revealed a diagnosis of [DIAGNOSES REDACTED]" Review of the admission note at 2247 revealed, "[AGE] year old male patient in room 7 brought in with a self-inflicted knife wound to his left arm. Patient was very upset but polite and cooperative and stated that he feels bad that he did this to himself, that he really doesn't want to kill himself. He stated that he has no family that cares about him and he feels like he has nobody. Patient also stated that he feels like this episode is a 'set back' and he just needs someone to talk to... Patient is presently sitting in his room talking with security and is calm and cooperative." Review of "Nurses Notes" by RN #2 on 04/26/2016 at 0146 revealed, "Patient remains in Room #7. He became very agitated earlier because he wanted to leave. This RN explained that ED was very busy with many very sick patients and he apologized and calmed down."

Record review revealed the following labs were ordered and completed on Pt # 25:
Urine Drug Screen STAT (results within the identified Reference Range), TSH 2.62 (Reference Range: 0.34 -5.60); Alcohol, serum 186 (Reference Range: <5); Comprehensive Metabolic Profile: BUN 7 (Reference Range: 8-20), Potassium 3.5 (Reference Range: 3.6-5.1); CO2 22 (Reference Range: 25-34); Complete Blood Count: Hemoglobin 16.3 (Reference Range: 4.27-5.49), Hematocrit 48.8 (Reference Range: 37.7-46.5); Drug Screen STAT: Cannabinoid (Marijuana) Positive (resulted at 2233). Continued review revealed Physician A was notified of abnormal results on 04/26/2016 at 0251 and abnormal vital signs 04/26/2016 at 0252 by RN #3. Review revealed a medication order was entered by Physician A for Patient #25 at 2235 for a Tdap (Tetanus, [DIAGNOSES REDACTED], and Acellular Pertussis- vaccination against three infectious diseases) vaccine 0.5 ML (milliliters) IM (intramuscular) once and was administered by RN #4 at 0116.

Review of the "Close Observation Form" revealed Patient #25 was placed on 1:1 observation. Review revealed the patient was "Agitated" at 2200, then "Cooperative" and "Calm. Review revealed Pt # 25 was "Restless" at 0045-0100. Review revealed "Pt Left" documented following the 0200 observation.

Review of the Medical Screening Exam (MSE) by Physician A at 2202 revealed the patient had "rambling conversation", "Anxious", "Below Average Insight", and "Below Average Judgement." Review of Systems (ROS) revealed, "Psychiatric: Anxiety, depression ...Sleepless, Suicidal" were indicated. Continued review of the MSE revealed no consultation orders. Review of a Procedure Note "Laceration Repair" summary by Physician A, revealed Patient #25 presented with a 6.5 cm (centimeter) laceration and a 5 cm laceration on the "L (left)Volar Forearm", which were closed with Dermabond (used to close wounds from small lacerations that do not require sutures). Review of the MSE documentation at 0135 revealed, " 1. Superficial laceration x2 L (left) wrist 2. Depression 3. SI (Suicidal Ideation) 4. Suicidal Gesture 5. ETOH (Ethyl Alcohol) Intoxication 6. IVC (Involuntary Commitment). Review revealed no available documentation of initiation for the IVC per policy for review. Further review revealed, "Pt walked out of our ED room while waiting for IVC papers to be returned" noted on the MSE by Physician A at 0210. Further review revealed a circle around "AMA due to" and "Patient refuses". Review of the Discharge section of the record revealed "...Status: discharged ....Condition: Good....Emergency discharge date /Time: 04/26/2016 02:10 Emergency Discharge Disposition: WALKOUT-POST ROOM (ER ONLY). ..."

Medical Record review did not reveal any signed AMA paperwork. Review revealed no available documentation of circumstances surrounding the patient's departure from the facility during the process of being IVC'ed. Further record review revealed no available nursing documentation of circumstances surrounding the patient's departure from the facility during the process of being IVC'ed, the patient's status prior to walking out of the ED while IVC paper work was being processed, or actions taken by hospital staff during or after the event.

Closed DED record review, on 07/22/2016, revealed Pt # 25 returned to the DED via police car on 04/26/2016 at 1700 (Visit # 2) (15 hours after leaving the DED) in the custody of Law Enforcement (Officer #3) under IVC. Review revealed (Officer #3) presented an "AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT" to the triage nurse upon arrival. Review revealed Physician A initiated petition for Involuntary Commitment (IVC) (no date/time listed). Review of the document revealed the patient was, "mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness." Review revealed, "Pt (Patient) has been very depressed over relationship, job loss & finances attempted to kill himself by cutting his wrists. tonight expresses continued suicidal ideation." Review of the "EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT" (no date or time), "SECTION I - CRITERIA FOR COMMITMENT Inpatient. It is my opinion that the respondent is: mentally ill; dangerous to self; ..." Review of "SECTION II - DESCRIPTION OF FINDINGS" revealed, "Pt states depressed and stressed out over relationships, finances, job loss Wants to die & attempted to kill himself by cutting wrists tonight and expresses continued suicidal ideation." Review revealed request for a seven (7) day Inpatient Commitment due to mental illness and "dangerous to self or others." Further review revealed a "FINDINGS AND CUSTODY ORDER FOR INVOLUNTARY COMMITMENT" was issued by the Magistrate on 04/26/2016 at 0314, the patient was taken into custody on 04/26/2016 at 1700, and was escorted to the hospital's DED for further psychiatric evaluation, stabilization, and treatment.

Record review revealed a second "EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT" was performed by Physician C, on 04/26/2016 at 1808 requesting a three (3) day Inpatient Commitment due to mental illness and "...dangerous to self or others....Impression/Diagnosis: Suicidal Attempt. L forearm Lacerations. "

Further record review revealed a third "EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT", (no date or time), was initiated by Physician D. Review of "Section II-Description of Findings" revealed, "Pt regrets decision, stating, 'retarded...Will never do again' Denies S/I - set up with out pt [sic]. No danger to self. Safe for Out patient [sic]." Review revealed, "Release Respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria)." Review revealed the form was electronically signed by Physician D on 05/12/2016 at 1624. Review of nursing documentation on 04/28/2016 at 0935 revealed, "(Physician D) on unit to assess pt. Recommends overturning IVC and has started process to attend (Outpatient Treatment Facility) out pt [sic]. denies s/i or h/i (suicidal ideation or homicidal ideation). (Family member) states can come at 2 to bring pt home." Review revealed Patient #25 was discharged home at 1249 with (Officer #3).

Review of the "(Hospital A) DAILY SECURITY REPORT" dated 04/25/2015 for 1600-0030 revealed (Officer #1) was "Called to sit with a patient in Room #7" in the ED at 2204, with no additional information available for review. Review of report dated 04/26/2016 for 2400-0830 revealed (Officer #2) "Took IVC papers to magistrate office." Review did not reveal a call to security after Pt # 25 left the hospital AMA.
Review of Occurrence Reports did not reveal an incident report related to Pt # 25 leaving the hospital AMA on 04/26/2016.

Staff interview on 07/22/2016 at 1600 with the DED Manager #1 revealed the physician who cared for Pt # 25 was not available for interview. Interview revealed there was no available documentation of the Sheriff's department being notified when Patient #25 "walked out" of the ED after IVC paperwork was initiated. Interview revealed, "I can't say they were because there is no documentation." Interview revealed nursing staff in the ED have been instructed not to try and stop a patient who is trying to leave. Interview revealed nursing staff have been instructed to try to convince the patient to stay and explain the importance of evaluation but if the patient is insistent on leaving and there may be a possibility of them becoming angry or aggressive, the staff are to take a supportive stance, and step aside if the situation escalates. They are told not to try to force the patient back in." Interview revealed ED staff are currently being trained on "Commitment....policies" and may not be aware of steps to take when a patient leaves while IVC paperwork is being processed. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 4/25/2016 when Patient #25 openly expressed a desire to leave the ED, there was no documentation in the medical record to support that a staff member met with patient #25, immediately to explore with the patient concerns jeopardizing ongoing and needed treatment for his psychiatric emergency medical condition.. As Patient #25 was on IVC hold in the ED and was considered to be a danger to himself and others expressing suicidal thoughts and was considered unstable on Visit #1, and was allowed to leave the ED.

Another interview at 1635 with DED Manager # 1 revealed the manager did not remember this specific incident. Interview revealed "This is the first time I've heard about this case. ..." Interview revealed that although nursing staff have been instructed not to interfere with a patient who is leaving the hospital, the expectation is that the police would be notified, as outlined in the policy and "...Should've made notes." Interview revealed an occurrence report should have been completed, as well as Against Medical Advise (AMA) paperwork, "but I don't have either of them." Interview revealed the patient was not placed in the ED 3 secured area because there were no available beds. Interview revealed Pt # 25 was placed in the safe room (#7) and assigned every 15 minutes checks on his initial ED visit. Interview revealed required documentation outlined in the hospital's Commit, D-50-ED-30 policy was not present or available. Further interview at 1700 revealed Patient #25 was picked up by the Sheriff's department on the IVC court order and returned to the ED under IVC on 04/26/2016 at 1700. Interview revealed the patient left the ED before the IVC paperwork was taken to the Magistrates office.
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