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.
| SOUTHEASTERN REGIONAL MEDICAL CENTER | 300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359 | Jan. 5, 2016 |
| VIOLATION: COMPLIANCE WITH 489.24 | Tag No: A2400 | |
| Based on hospital policy and procedure reviews, medical record reviews, hospital documents review and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings include: 1. The hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 11 patients who presented to the DED with a psychiatric complaint (#4). ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A2406. 2. The Dedicated Emergency Department (DED) failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 11 patients with a psychiatric emergent medical conditions (#4). ~ Cross refer to 489.24(d)(3) Stabilizing Treatment - Tag A2407. |
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| VIOLATION: MEDICAL SCREENING EXAM | Tag No: A2406 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure reviews, medical record reviews, hospital documents review, staff and physician interviews the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 11 patients who presented to the DED with a psychiatric complaint (#4). The findings include: Review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", Revised 11/13/2012 revealed..B. Medical Screening Examination: 1. Any individual who presents to XYZ Medical Center seeking emergency care shall undergo a medical screening examination to determine whether that the individual is experiencing an emergency medical condition.. Generally, an "emergency medical condition" is one manifesting such symptoms (including severe pain, psychiatric disturbances, and or other symptoms of substance abuse) that the absence of immediate medical attention is likely to cause serious dysfunction or serious jeopardy to the health of the individual... 4. The exam shall include those ancillary services routinely available to, although not located in Emergency Services.. including on-call physicians... D. Stabilization: 1. Any individual experiencing and emergency medical condition must be stabilized prior to transfer or discharge..." Closed DED medical record review on 01/05/2016 revealed Patient #4, a [AGE] year-old male (MDS) dated [DATE] at 1913 via EMS (emergency medical services) for a chief complaint of "Overdose- multiple medications" . Medical record review of triage documentation at 1915 revealed " Pt states that he took 3 800mg ibuprofen (anti-inflammatory), 2 hydrocodone (narcotic pain medication) 10-325mg and mirtazide (anti-depressant) 2 tabs. Pt reports he was depressed and hurting and wanted to stop hurting " . Review of nursing documentation at 1940 revealed "Wife with patient ... Pt has a history of depression and states that he wants to hurt himself to 'make the pain go away' ..Pt ' s wife also stated that he had not been taking his medications for about a week and started to feel depressed last night ...Pt in view of sitter." Record review revealed DED Physician (Physician #1) MSE began at 2011. Review of DED Physician documentation revealed "HISTORY OF PRESENT ILLNESS: "The patient reports he was having low back pain and had forgotten that he took his first anti-depressant before taking another. The ingestion was accidental.... REVIEW OF SYSTEMS: Psychiatric: (-) emotional stress... PAST MEDICAL HISTORY: (+) DJD (degenerative joint disease)..PHYSICAL EXAMINATION: GENERAL APPEARANCE: Patient is alert, lethargic and in no distress. Patient is avoidant of exam...PSYCH: (-) apparent hallucinations or delusions. Affect: normal..." Review of record revealed laboratory studies ordered included: CBC (complete blood count), Chemistry, Cardiac Panel, Blood alcohol, Salicylate (asprin) level, acetaminophen level, urinalysis, drug abuse screen-urine, urine microscopic and drug of abuse med 9 panel which revealed the patient was positive for opiates (narcotics). Record revealed CT scan of the brain without contrast was completed with "No evidence of acute intracranial pathology." Review of nursing documentation at 2240 revealed "Pt is resting in bed... sitter and family at bedside." Review of "Suicide Precaution Sitter Form" revealed sitter at bedside with the patient from 2000-0000 (until discharge). Record review revealed disposition to discharge was set by DED Physician (Physician #1) at 2334 with the "condition at discharge: improved." Record review revealed the patient was diagnosed with Polypharmacy (multiple medication use) and Asthenia (weakness) and given instructions for near syncope and weakness. Record review revealed he was to follow up with his primary physician in 3-5 days. The patient was discharged home at 0011 on 08/28/2015. Record review revealed no documentation of a psychiatric assessment of the patient prior to discharge. Closed medical record review revealed Patient #4 was pronounced DOA (dead on arrival) to the DED on 09/01/2015 at 1645 from a gunshot wound to the head. ( 4 days after discharge from the DED). Review of grievance documentation revealed Patient #4's sister met with the hospital's Manager of Patient Relations to file a complaint on 09/29/2015. Documentation revealed the "sister stated that when she tried to share with Dr. XXXX (DED Physician) the patient's history of depression, and her serious concern for mental health, DED Physician said something to the effect that he was not interested in the patient's history, but would be treating the current emergency... felt that he was in a hurry and not compassionate, noted by his walking backwards out of the room as she was speaking with him..." Review of the Psychiatry on-call roster for August 2015 revealed there was on-call coverage every day of the month. Interview on 01/05/2016 at 1530 with ED Nurse Manager revealed DED Physican (Physician #1) is a Locum (contract physician) and not employed by the hospital and has not been scheduled since September 2015 and therefore not available for interview. Interview on 01/06/2016 at 0930 with Administrative Nurse#1 revealed Emergency Department nurses can use their judgement if they feel a patient is a danger to themselves to place them on "Suicide Precautions" with a sitter for monitoring. Interview on 01/06/2016 at 1130 with ED Medical Director revealed he learned about the patient when the case came through quality. Interview revealed that he has reviewed the chart and feels the patient had an appropriate medical screening exam. DED Physician is "still on staff and would not hesitate to put him back on the schedule". |
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| VIOLATION: STABILIZING TREATMENT | Tag No: A2407 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure reviews, medical record reviews, staff and physician interviews, the Dedicated Emergency Department (DED) failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1of 11 patients with psychiatric emergent medical conditions (#4). The findings include: Review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", Revised 11/13/2012 revealed... D. Stabilization: 1. Any individual experiencing and emergency medical condition must be stabilized prior to transfer or discharge..." Closed DED medical record review on 01/05/2016 revealed Patient #4, a [AGE] year-old male (MDS) dated [DATE] at 1913 via EMS (emergency medical services) for a chief complaint of "Overdose- multiple medications" . Medical record review of triage documentation at 1915 revealed " Pt states that he took 3 800mg ibuprofen (anti-inflammatory), 2 hydrocodone (narcotic pain medication) 10-325mg and mirtazide (anti-depressant) 2 tabs. Pt reports he was depressed and hurting and wanted to stop hurting " . Review of nursing documentation at 1940 revealed "Wife with patient ... Pt has a history of depression and states that he wants to hurt himself to 'make the pain go away' ..Pt ' s wife also stated that he had not been taking his medications for about a week and started to feel depressed last night ...Pt in view of sitter." Record review revealed DED Physician (Physician #1) MSE began at 2011. Review of DED Physician documentation revealed "HISTORY OF PRESENT ILLNESS: "The patient reports he was having low back pain and had forgotten that he took his first anti-depressant before taking another. The ingestion was accidental.... REVIEW OF SYSTEMS: Psychiatric: (-) emotional stress... PAST MEDICAL HISTORY: (+) DJD (degenerative joint disease)..PHYSICAL EXAMINATION: GENERAL APPEARANCE: Patient is alert, lethargic and in no distress. Patient is avoidant of exam...PSYCH: (-) apparent hallucinations or delusions. Affect: normal..." Review of record revealed laboratory studies ordered included: CBC (complete blood count), Chemistry, Cardiac Panel, Blood alcohol, Salicylate (asprin) level, acetaminophen level, urinalysis, drug abuse screen-urine, urine microscopic and drug of abuse med 9 panel which revealed the patient was positive for opiates (narcotics). Record revealed CT scan of the brain without contrast was completed with "No evidence of acute intracranial pathology." Review of nursing documentation at 2240 revealed "Pt is resting in bed... sitter and family at bedside." Review of "Suicide Precaution Sitter Form" revealed sitter at bedside with the patient from 2000-0000 (until discharge). Record review revealed disposition to discharge was set by DED Physician (Physician #1) at 2334 with the "condition at discharge: improved." Record review of physican notes revealed "EMERGENCY DEPARTMENT COURSE AND TREATMENT: Given the nature of the ingestion and the and the available information the patient was not placed on continuous observation status immediately..On reassessment Patient is awake, alert and in no acute distress and stable for discharge..." Record review revealed the patient was diagnosed with Polypharmacy (multiple medication use) and Asthenia (weakness) and given instructions for near syncope and weakness. Record review revealed he was to follow up with his primary physician in 3-5 days. The patient was discharged home at 0011 on 08/28/2015. Record review revealed no documentation of a psychiatric assessment of the patient prior to discharge. Closed medical record review revealed Patient #4 was pronounced DOA (dead on arrival) to the DED on 09/01/2015 at 1645 from a gunshot wound to the head. ( 4 days after discharge from the DED). Review of grievance documentation revealed Patient #4's sister met with the hospital's Manager of Patient Relations to file a complaint on 09/29/2015. Documentation revealed the "sister stated that when she tried to share with Dr. XXXX (DED Physician) the patient's history of depression, and her serious concern for mental health, DED Physician said something to the effect that he was not interested in the patient's history, but would be treating the current emergency... felt that he was in a hurry and not compassionate, noted by his walking backwards out of the room as she was speaking with him..." Review of the Psychiatry on-call roster for August 2015 revealed there was on-call coverage every day of the month. Interview on 01/05/2016 at 1530 with ED Nurse Manager revealed DED Physican (Physician #1) is a Locum (contract physician) and not employed by the hospital and has not been scheduled since September 2015 and therefore not available for interview. Interview on 01/06/2016 at 0930 with Administrative Nurse#1 revealed Emergency Department nurses can use their judgement if they feel a patient is a danger to themselves to place them on "Suicide Precautions" with a sitter for monitoring. Interview on 01/06/2016 at 1130 with ED Medical Director revealed he learned about the patient when the case came through quality. Interview revealed that he has reviewed the chart and feels the patient had an appropriate medical screening exam. DED Physician is "still on staff and would not hesitate to put him back on the schedule". NC 882 |
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