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|SANDHILLS REGIONAL MEDICAL CENTER||1000 WEST HAMLET AVENUE HAMLET, NC 28345||Nov. 24, 2015|
|VIOLATION: COMPLIANCE WITH 489.24||Tag No: A2400|
|Based on hospital policy reviews, Sheriff's Office operations report review, medical record reviews, dedicated emergency department (DED) daily staffing assignment sheet review, DED central log review, DED diversion log review, DED daily safety huddle record review, census reports review, Sheriff's Deputy interviews, and staff interviews, the hospital failed to comply with 42 CFR 489.24.
The findings include:
The hospital's DED 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 1 patients (#21) who presented onto the hospital's property under involuntary commitment (IVC) order via Sheriff's Deputy and was diverted to another acute care hospital without being registered or evaluated in the DED at Hospital A.
~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.
|VIOLATION: MEDICAL SCREENING EXAM||Tag No: A2406|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy reviews, Sheriff's Office operations report review, medical record reviews, dedicated emergency department (DED) daily staffing assignment sheet review, DED central log review, DED diversion log review, DED daily safety huddle record review, census reports review, Sheriff's Deputy interviews, and staff interviews, the hospital's DED 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 1 patients (#21) who presented onto the hospital's property under involuntary commitment (IVC) order via Sheriff's Deputy and was diverted to another acute care hospital without being registered or evaluated in the DED at Hospital A.
The findings include:
Review on 11/24/2015 of current hospital policy "Emergency Medical Treatment and Patient Transfer - G2", revised 09/2013, revealed "...Definitions For the purpose of this EMTALA Policy, the following terms are defined as follows: ...Comes to the Emergency Department with respect to an individual requesting examination and treatment means the individual is on the Hospital Property (including parking lot, campus, ambulance bay, and other department of the Hospital)... Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including....psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual....in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part;... Hospital Property or Premises includes the entire main Hospital campus, including the parking lot, sidewalk and driveway. ...Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists....Such screening must be done within the Hospital's Capacity and Capability and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or Appropriately Transferred. ...I. MEDICAL SCREENING EXAMINATION A. General 1. Medical Screening. When an individual comes to the Emergency Department of the Hospital, or to any location on the Hospital's campus....and a request is made on the individual's behalf for a medical examination or treatment, an appropriate Medical Screening Examination, within the Capabilities of the department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an Emergency Medical Condition exists....The record must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, discharged , admitted , or appropriately transferred. Medical Screening Examinations shall be performed by an Emergency Department physician or another licensed practitioner as appointed and approved by the Hospital's Medical Staff and Board of Trustees....An Emergency Department physician on duty shall be responsible for the general care of all patients presenting themselves to the Emergency Department. This responsibility remains with the Emergency Department physician until the patient's private physician or an on-call specialist assumes that responsibility, or the patient is appropriately discharged or arrives at the receiving hospital following appropriate transfer. ...6. Emergency Department Log. The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance and indicate whether the individual refused treatment....or was transferred, admitted and treated, stabilized and transferred, or discharged . ..."
Review on 11/24/2015 of current hospital policy "Transfer of Patient to Another facility and or Diversion" effective date: 06/06/2014, revealed "...Responsibility/Authority: ...A transfer diversion log will be maintained in the Emergency Department, to document times and dates of diversion status. ...Emergency Department diversion is defined as No bed Availability....or 2 or more Behavioral Health holds in the ER ..."
Review on 11/24/2015 of an XYZ County Sheriff's Office, "Operations Report" for case number: , dated 11/24/2015, provided by Sheriff's Lieutenant #1 revealed, "Date/Time Received" with "11/10/2015 16:05" noted. Review revealed, "Nature of Incident " with "INVOL - INVOLUNTARY COMMITMENT" noted. Review revealed, "Victim Complainant Accused" with "(Patient #21 last name)" noted. Review revealed, "Action Taken" with "136 (Deputy #1's badge number) TRANSPORTING SUBJECT (Patient #21) TO (Hospital A name) 16:08." Review revealed "161 (Deputy #2 name) & 132 (Deputy #3 name) AT (Hospital A name) with 136 16:15." Review revealed, "(RN #1 name) FROM (Hospital A name) ADVISED THEY ARE STILL ON PSYCHIATRIC DIVERSION AND HAVE BEEN SINCE 11/09/2015 11:30." Review revealed, "TRANSPORTING SUBJECT TO (Hospital B name) 16:22." Review revealed, "161 & 132 10-17 (enroute) TO (Hospital B name) 16:22." Review revealed, "136 AT (Hospital B name) 16:28..."
Hospital B, closed DED record review on 11/23/2015 for Patient #21 revealed a [AGE] year old male presented under IVC order via Sheriff's Deputy to Hospital B's DED on 11/10/2015 at 1631 (9 minutes after departure from Hospital A at 1622). Review of a "Findings and Custody Order Involuntary Commitment" dated 11/10/2015, signed by a Magistrate at 1435 revealed the "Respondent" was Patient #21. Review revealed "I. FINDINGS The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent is probably: ...[X] 1. 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. ...II. CUSTODY ORDER TO ANY LAW ENFORCEMENT OFFICER: The Court ORDERS you to take the above named respondent into custody WITHIN 24 HOURS AFTER THIS ORDER IS SIGNED and take the respondent for examination by a person authorized by law to conduct the examination. ..." Further review revealed the respondent was presented to Hospital B on 11-10-2015 at 1630 by Deputy #2. Review revealed the patient was triaged by a Registered Nurse (RN) at 1637. Review revealed a chief complaint of "IVC." Review of nursing triage HPI (history of present illness) revealed "Psychiatric Evaluation - Pt (patient) brought by law enforcement for psychiatric evaluation. ...Pt has had 2 similar episodes over past years." Review revealed vital signs were assessed as Blood Pressure (BP) 145/78, Pulse (P) 101, Respirations (R) 20, Oxygen Saturation (O2Sat) 100% on room air (RA), and Temperature (T) 99.5 degrees Fahrenheit (F). Review revealed pain was assessed as "denies pain." Review revealed the patient was assigned a triage acuity of 2 (1 most severe, 5 least severe). Review revealed an MSE was conducted by Physician A at 1641. Review of MSE documentation revealed "PHYSICIAN H&P [history and physical] (Psych Medical Clearance) ...HPI: Pt brought by law enforcement for psychiatric evaluation. Law enforcement states patient's father requested IVC. Other Symptoms (psych): (-) [negative] suicide attempt, (-) suicidal ideations, (-) homicidal ideations/attempt, (?) [Questionable] visual hallucinations, (?) auditory hallucinations....Apparently hospitalized for 10 days several years ago @ (at) (Hospital A); pt does not know why. I discussed the patient's behavior with his father, who initiated the involuntary commitment. Father relates that the patient has a prior history of paranoid schizophrenia, but ultimately was lost to followup, declines treatment, and is no longer her [sic] to the care of her [sic] behavior health professional. He does relate that he previously smoked marijuana, but does not abuse drugs in years. He additionally states that the patient seems to be having auditory hallucinations, flight of ideas, and has occasionally become threatening and violent. The sheriff accompanied the patient relates that the patient was [sic] previously become violent in the past." Review of ROS (review of systems) revealed psychiatric history was negative for anxiety, bipolar, depression, personality disorder, and schizophrenia. Review of physical exam revealed, "...GENERAL APPEARANCE (psyc): - well nourished, well groomed, alert, cooperative, speech normal rate, speech normal volume, speaks with coherent and with logical thoughts. MENTAL STATUS: speech clear, oriented X3 (person, place, and time), normal affect, responds appropriately to questions. ..." Review of "Decision Making" revealed, "Records received from (Hospital A). Patient was admitted in May of 2010, with a final diagnosis of rule out schizoid personality disorder." Review revealed "Summary: Patient presents with Sheriff's office in possession of order for involuntary commitment; patient has a history of schizoid personality disorder, is medically clear, may represent a threat to others, I concur with the requirement for involuntary commitment and further behavioral health evaluation." Review revealed "IMPRESSION: likely schizoid personality disorder." Review revealed "Diagnosis/Instructions Dx 1: Schizoid personality disorder." Review revealed "Disposition Transfer to (Hospital C)." Review of an "Examination and Recommendation to Determine Necessity for Involuntary Commitment" form revealed the form was completed by Physician A on 11/10/2015 at 1700. Review of "SECTION I - CRITERIA FOR COMMITMENT" revealed, "Inpatient. It is my opinion that the respondent is: [check in box] mentally ill; ...[check in box] dangerous to others..." Review of "SECTION II - DESCRIPTION OF FINDINGS" revealed, "History of schizoid personality disorder communicated threats to father reported history of violent outburst (by sheriff) No history of recent substance abuse ...Impression/Diagnosis: Schizoid Personality Disorder." Review of "SECTION III - RECOMMENDATION FOR DISPOSITION" revealed, "[check mark in box] Inpatient Commitment for 3 days..." Record review revealed the patient was transferred to Hospital C via Sheriff's Deputy on 11/11/2015 at 1700.
Hospital C, closed medical record review on 11/23/2015 for Patient #21 revealed the patient was admitted to the hospital's in-patient Behavioral Health unit on 11/11/2015 and was discharged on [DATE]. Review of an admission History and Physical (H&P) dictated by Physician B on 11/12/2015 at 1021 revealed "DATE OF ADMISSION: 11/11/2015." Review revealed, "CHIEF COMPLAINT AND REASON FOR ADMISSION: Involuntary commitment and petition taken out by his father for paranoid and threatening behavior. ...IMPRESSION: AXIS I: Psychotic disorder, not otherwise specified, provisional. ..." Review of a discharge summary dictated 11/13/2015 at 0956 by Physician B revealed "DATE OF DISCHARGE: 11/13/2015." Review revealed, "DISCHARGE DIAGNOSES: AXIS I: Psychotic disorder, not otherwise specified which is principal and primary diagnosis. ...FOLLOWUP: With (Mental Health Agency name). ..."
Review on 11/24/2015 of Hospital A's DED daily "Assignment sheet" for 11/10/2015 revealed RN #1 was on-duty during the 0700 to 1900 shift. Review revealed RN #1 was the "Charge Nurse."
Review on 11/23/2015 of Hospital A's DED Central Log for 11/10/2015 (date Patient #21 presented on Hospital A's property via Deputy #1 for evaluation) from 0000 to 2359 failed to reveal any available documentation Patient #21 was registered as a patient in the DED during the time frame (1615-1622) he presented on hospital property under IVC and in the custody of Deputy #1.
Review on 11/24/2015 of Hospital A's DED "Diversion Log" from 11/28/2014 to 11/24/2015 revealed the DED had been on psychiatric diversion a total of 11 times. Review revealed the DED went on psychiatric diversion on 11/09/2015 at 1135. Review revealed "Time/Name EMS - 911 notified: (City #1 name) PD (police department) 1137, (City #2 name) PD 1138, (XYZ County) SD (Sheriff's Office) 1139, E Comm (Emergency Communications) 1142 [all handwritten]." Review revealed "Time/Name Hospitals notified: (Hospital B), (Hospital C) 1145, Magistrate @ (at) 1146 [all handwritten]." Review revealed the signature of RN #1 at 1135. Review revealed the time the diversion ended was not documented. Review of the diversion log failed to reveal any available documentation the ED was on diversion status on 11/10/2015. Continued review of Hospital A's DED "Diversion Log" revealed the DED went on psychiatric diversion on 11/11/2015 at 1100 and ended on 11/12/2015 at 1100.
Review on 11/24/2015 of Hospital A's DED "Daily Safety Huddle Record" dated 11/10/2015 (not timed) [date Patient #21 presented on hospital property via Deputy #1 for evaluation] revealed, "Check-in Leader" with RN #1's name listed. Review revealed, "Any safety issues or challenges in the last 24 hours?" with "2 psych (psychiatric) holds - 1 ped (pediatric), 1 psych in the door @ 0740 (handwritten)" under the column "Issue/Challenge." Review revealed, "On dervision [sic] still awaiting bed availability (handwritten)" under the column "Follow-up Required..." Further review revealed "Any anticipated issues or challenges for the next 24 hours?" with "mental health holds - placement (handwritten)" under the column "Issue/Challenge." Further review revealed "On dervision [sic] still awaiting bed availability (handwritten)" under the column "Follow-up Required..."
Review on 11/24/2015 of Hospital A's "Midnight Census Listing by Floor" dated 11/10/2015 at 2359 and "Psychiatric Census List by Floor" dated 11/11/2015 at 0300 revealed the hospital's Behavioral Health Unit (BHU) had a census of 10 of 10 beds occupied on the date Patient #21 presented on hospital property for evaluation via Deputy #1. Review revealed the BHU was at licensed capacity (10). Review revealed the current BHU patients' length of stays ranged from 1 to 8 days.
Telephone Interview on 11/24/2015 at 0820 with Sheriff's Lieutenant #1 revealed he was a Lieutenant with the XYZ County Sheriff's Office. Interview revealed he was the Shift Supervisor on-duty when Deputy #1 contacted him on 11/10/2015 for direction. Interview revealed Deputy #1 contacted him because Hospital A was on psychiatric diversion and nursing staff told Deputy #1 he needed to take the patient to another hospital. Interview revealed he instructed Deputy #1 to take the patient to Hospital B. Interview revealed "It is not a normal occurrence." Interview revealed all psychiatric patients are normally taken to Hospital A because it has a psychiatric unit. Interview revealed "we have always had a good working relationship with the hospital."
Interview on 11/24/2015 at 0912 with Deputy #1 revealed he was a Sheriff's Deputy with XYZ Sheriff's Office. Interview revealed he had been with the Sheriff's Office for 9.5 years. Interview revealed on 11/10/2015 he picked up Patient #21 from his residence and transported him to Hospital A for evaluation. Interview revealed the patient was under IVC. Interview revealed he drove up in his patrol car with the patient and parked under the hospital's canopy in front of the ambulance bay entrance. Interview revealed Patient #21 was polite and cooperative and requested to smoke a cigarette before going into the ED. Interview revealed he allowed the patient to smoke a cigarette outside before entering the ED. Interview revealed he walked into the ED area with the patient. Interview revealed they walked through the ambulance bay doors. Interview revealed they walked to the nurses' desk when he was told the ED was on psychiatric diversion and could not take the patient. Interview revealed he contacted Lieutenant #1 and he directed him to take the patient to Hospital B. Interview revealed the patient was in handcuffs. Interview revealed he did not recall the name of the ED staff member who told him the ED was on diversion. Interview revealed "it was a nurse." Interview revealed he left Hospital A's DED with the patient and transported him to Hospital B. Interview revealed "this has never happened before." Interview revealed the next day he picked up an IVC and brought them to Hospital A and they took the patient without issue. Interview revealed a nurse at Hospital B asked what happened and he "told the story." Interview revealed his badge number was 136.
Interview on 11/24/2015 at 0954 with RN #1 revealed she was an employee of Hospital A in the ED. Interview revealed she was the ED charge nurse on 11/10/2015 from 0700-1900. Interview revealed "we have been told that if mental health (Behavioral Health Unit) is full and we have 2 or more psych patients in the ED, we are to go on psych diversion." Interview revealed there is a policy in place for diversion. Interview revealed diversion is for psych patients only and not medical. Interview revealed "we rarely go on diversion." Interview revealed the ED maintains a "diversion log." Interview revealed the ED went on diversion on 11/09/2015 at 1135. Interview revealed she does not know when it ended. Interview revealed the time diversion ended was not documented on the log. Interview revealed "when I left shift on 11/10/2015 at 7 PM, we were still on diversion." Interview revealed "mental health was full and we were keeping 2 in the ED." Interview revealed "an officer came into the ED through the ambulance bay doors and asked 'are y'all still on psych diversion?'" Interview revealed "I told him yes." Interview revealed "the officer walked back out the door." Interview revealed "he was talking on the phone." Interview revealed "the officer was alone." Interview revealed the officer was "the one you (Surveyor) were talking to (Deputy #1)." Interview revealed there was no patient accompanying the officer. Interview revealed the officer did not notify staff he had a patient with him. Interview revealed she did not see a patient. Interview revealed she did not ask the officer if he had a patient with him. Interview revealed she had no further conversation with the officer. Interview revealed she was at the nurses' station when the officer entered the ED. Interview revealed if a patient is brought to the ED by law enforcement they must be registered and evaluated, regardless of diversion status. Interview revealed "they cannot be turned away."
Interview on 11/24/2015 at 1020 with Nurse Manager #1 revealed she was the interim ED nurse manager for Hospital A. Interview revealed she was in the ED on 11/10/2015, walking through the department checking on staff. Interview revealed she recalled 2 officers went outside then a Sheriff's Deputy came into the ED and was talking on the phone. Interview revealed the Deputy entered the ED through the ambulance bay doors. Interview revealed she was not certain of the Deputy's name. Interview revealed the Deputy looked at the nurses and asked if the ED was still on psychiatric diversion and RN #1 answered yes. Interview revealed the Deputy turned around and exited the ED. Interview revealed the Deputy was alone. Interview revealed the Deputy did not mention having a patient in his patrol car. Interview revealed RN #1 did not ask the Deputy if he had a patient with him. Interview revealed she was unaware a patient was on the hospital property in the custody of the Deputy. Interview revealed psychiatric diversion occurs only when the mental health unit is full and the ED is holding 2 patients under IVC. Interview revealed the staff follow the diversion policy and are supposed to notify 911, magistrate's office, local hospitals and law enforcement agencies when the hospital goes on and off diversion status. Interview revealed if a patient is brought on hospital property, regardless of diversion status, "we must still see the patient and perform a MSE."
Interview on 11/24/2015 at 1359 with CEO #1 and CNO #1 for Hospital A, revealed they had no knowledge of any incident involving an XYZ County Sheriff's Office Deputy presenting on hospital property on 11/10/2015 with an IVC patient seeking evaluation and being diverted to another hospital because the ED was on psychiatric diversion.