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MARGARET R PARDEE MEMORIAL HOSPITAL 800 N JUSTICE ST HENDERSONVILLE, NC 28791 June 15, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy and procedure review, closed medical record reviews and staff interviews the facility failed to ensure compliance with 42 CFR 489.24.

Findings included:

1. Based on policy review, closed medical record review, Involuntary commitment papers, staff and physician interviews, the hospital staff failed to: A) provide stabilizing treatment as required to an individual with and identified psychiatric emergency medical condition for 1 of 6 (#7) patients with psychiatric/behavioral health complaints that presented to the hospital's DED (dedicated emergency department) requesting treatment and B) to take reasonable steps to obtain a patient's written informed refusal for examination or treatment in 1 of 5 patients the staff knew were leaving without treatment (LWOT) or Against Medical Advice (AMA) from the DED (#3).

~ 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 policy review, closed medical record review, Involuntary commitment papers, staff and physician interviews, the hospital staff failed to: A) provide stabilizing treatment as required to an individual with and identified psychiatric emergency medical condition for 1 of 6 (#7) patients with psychiatric/behavioral health complaints that presented to the hospital's DED (dedicated emergency department) requesting treatment and B) to take reasonable steps to obtain a patient's written informed refusal for examination or treatment in 1 of 5 patients the staff knew were leaving without treatment (LWOT) or Against Medical Advice (AMA) from the DED (#3).

The findings include:

A) Failed to provide stabilizing treatment

1. Medical record review of patient #7 revealed a [AGE] year old presenting to the DED on 5/9/2012 at 1514 with a chief complaint of Psychiatric evaluation involuntary commitment (IVC-a legal process through which an individual with severe mental illness is court ordered into treatment in a hospital) for alcohol abuse and suicidal ideations. Record review revealed the patient arrived at 1514 in police attendance. Record review revealed the patient's sister and the mobile crisis staff had initiated IVC process. Record review revealed the patient was triaged at 1524 with blood pressure 143/107 and complained of generalized pain at a rate of 9 on a 10 point scale with 10 being worst pain. Medical record review revealed documentation for the petition for IVC dated 5/9/2012 at 1445. Review of the documentation by the Mobile Crisis Responder revealed "Mentally ill and dangerous to self and others an in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness ... "Responder states he is diagnosed with Bipolar disorder and is currently manic , Respondent states he has not taken any mental health medication in approximately one year and instead " self medicates " with alcohol by drinking ...beers a day, Respondent states he has daily suicidal ideation with a plan to walk into traffic. Respondent states at least one suicide attempt in the past by walking into traffic. Respondent states he is "a dangerous man" and "could beat up anyone at any moment". Respondent states that he assaulted another man the night before (5/8) and doesn't know why. Respondent has been drinking presents with slurred speech and unsteady gait..."
Medical record review revealed Blood Alcohol Level (BAC) confirmed of 417.9 HC (Critical High (the identified Hospital normal reference range for BAC is negative notes ... " fatalities have been reported at levels greater that 400 mg/dL ") and results called to the DED staff by the Lab at 1710. Review of the urine drug screen at 1635 revealed positive results for Cocaine and APAP (Tylenol). Review of the nursing documentation revealed Security assisted with holding the patient for lab draws.
Medical record review revealed at 1623 the patient was "escorted back pt. (Patient) back to room with security officers help...very belligerent". Record review revealed nursing documentation at 1659 the patient comes out of his room and he "continues to be loud and verbal with staff. At 1712 nursing documented "Pt blood alcohol called as critical-417.9---Dr. XXX (name of physician) made aware. Pt remains loud and yelling about going out to smoke." Record review revealed at 1729 the patient was out of room "again and threatening to security and staff...leathers (restraints) placed as per MD orders". Record review revealed a physician's order at 1730 for behavioral restraints for Blood Alcohol 417.9 with the patient being out of bed, using poor judgement and falls risk. Review of the restraint flow sheet documentation by nursing revealed at 1730 the patient was restrained due to agitation, yelling noisy, verbally abusive and self-harm. Further review of the flow sheet revealed the patient continued agitated, yelling, noisy, verbally abusive and attempting to get out of bed until 1815. Nursing documentation revealed at 1945 the restrains were removed and psychiatric social worker staff were in to see the patient. Record review revealed at 2004 documentation by the psychiatric staff that the patient "firmly denies SI (suicidal ideations), HI (homicidal ideations), plan or intent...no Hx (history) of suicide attempts. Consulted with Dr. ZZZ (name of on call psychiatrist) who agrees with the plan of discharge". Record review revealed documentation by nursing staff at 2025 that the patient was having suicidal ideation and had previous suicide attempts by overdose. There was no documentation in the medical record to indicate that the ED nurse notified the ED physician or the on-call psychiatrist that patient #7 was having suicidal ideations, self-destructive behavior and verified previous suicidal attempts.

Review of the MSE started at 1554 revealed "Pt told Mobile crisis that he is "manic" has "daily SI"...associated symptoms angry, frustrated suicidal thoughts". Further review revealed at 1730 the patient was verbally abusive to the staff and continued to attempt to ambulate and was at risk for falling. MSE documentation review revealed the physician ordered "Restraint protocol" at 1730. Review of the MSE revealed at 2010 "Awake, alert ambulatory well. Pt has been cleared by Psych". Review of the MSE revealed the clinical impression was Alcohol intoxication and the patient was discharged home with condition "Improved".

Interview with DED administrative nursing staff on 6/13/2012 at 1000 revealed patient #7 is well known to the DED Staff and comes in often. The interview revealed the DED has psychiatric staff that assist with the assessment of the behavioral/mental health patients and placement of a patient. The interview revealed the documentation in the medical record by nursing timed at 2025 was "probably" a late entry and the assessment was completed earlier after triage. Documentation in the medical record verified that at 2026 patient #7 was still in the ED because vital signs were documented as Blood pressure 146/88; pulse rate: 98; respiratory rate was 18. The interview also revealed Patient #7 was in jail presently because he had "killed his best friend 2 days", after discharge from the DED on 5/9/2012.

Telephone interview with Psychiatric DED staff on 6/14/2012 at 1110 revealed she had assessed patient #7 on 5/9/2012. The interview revealed they assess the patient and call the psychiatrist on call and gives the physician the data collected from the assessment. The interview revealed the staff was not aware of documentation in the medical record of previous suicide attempts noted in the IVC petition paperwork and nursing assessment documentation. The interview revealed the IVC petition and nursing assessment were available for her review during the DED visit on 5/9/2012. The interview revealed the staff was not aware if the psychiatrist on call knew of Patient #7's history. The interview revealed had she known of the previous suicide attempts there would be no change in their recommendation to the psychiatrist. The facility failed to have an effective system to ensure that all information and clinical findings related to patient #7 was communicated to the ED physician and the on call psychiatrist to ensure patient #7 received definitive care.

Telephone interview with Dr. ZZZ (psychiatrist on call for DED on 5/9/2012) on 6/14/2012 at 1200 confirmed he was the psychiatrist on call for the DED on 5/9/2012. The interview revealed the physician was not familiar with patient #7 prior to 5/9/2012. The interview revealed the physician was not aware on 5/9/2012 that patient #7 had been restrained with leather restraints for behavioral reasons, his BAC level was 417.9 and that he had previous suicide attempts. The interview revealed this information would have been "key points" that would factor into the "decision making" process in the disposition of the patient. The facility failed to ensure that stabilizing treatment was provided as required for patient #7 on 5/9/2012 with identified psychiatric behavioral/ health complaints by failing to ensure the on call psychiatrist was accurately informed of the patient 's status while in the ED as evidenced by failing to inform the on call physician of the documented information on the IVC papers, that he was in leather restraints, BAC levels, and that the patient had a history of previous suicide attempts.
Interview with Dr. XXX (DED physician completing MSE for patient #7) on 6/14/2012 at approximately 1400 revealed he knew patient #7 "very well" due to his multiple visits to the DED in the past. The interview revealed after he evaluated patient #7 he reviewed the "old" medical record and knew he had previous suicide attempts. The interview revealed the psychiatric staff in the DED generally discuss findings with the on call psychiatrist and then let the DED know the recommendations. The interview revealed there was no need for a recheck of the BAC level due to patient #7's alcohol usage history.

B) Failed to take reasonable steps to obtain a patient's written informed refusal for examination or treatment

1. Medical record review of Patient #3 revealed a [AGE] year old presenting to the DED on 6/8/2012 at 0429 with a chief complaint of "need help, stress out, kill myself". Record review revealed the patient was triaged at 0437 and the physician started the Medical Screening Exam (MSE) at 0550. Review of the MSE revealed "suicidal thoughts, depression, started bingeing on cocaine last PM". Review of the MSE revealed the patient told the physician " 'I don't want to live any more' ". Record review revealed urine drug screen results were positive for cocaine and THC at 0635. Record review revealed documentation at 0723 "Pt (patient) is sleeping and unable to converse at this time [sic]. SW (Social worker) suggest that Pt be reevaluated at a later time this am (morning), Per report she has been voicing SI (suicidal ideations), hopelessness, and does not want to return...". Record review revealed at 0850 "Still awaiting SW eval". Record review revealed documentation by nursing at 0900 "Pt has decided to not wait and desires to leave.. Pt is not suicidal, and is A&Ox4, and is not involuntary." Record review revealed no documentation of written informed refusal for examination or treatment.

Interview with administrative DED Nursing staff on 6/14/2012 at 1615 revealed there was no further documentation for the record. The interview revealed staff are not aware to try to obtain written informed refusal. The interview revealed the hospital standard has been for the staff to only document what and when the patient makes staff aware the patient is leaving. The interview revealed the staff do not inform the patient of the risks of leaving.

NC 867