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.

Based on policy and procedure reviews, job description reviews, medical record reviews, hospital documentation reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.24.

The findings include:

The Dedicated Emergency Department (DED) physician 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 9 patients with psychiatric emergent medical conditions (#4).

~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

Based on policy and procedure reviews, job description reviews, medical record reviews, hospital documentation reviews, staff and physician interviews the Dedicated Emergency Department (DED) physician 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 9 patients with psychiatric emergent medical conditions (#4).

The findings include:

Review of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment PC 210.59", revised 06/2011 revealed "E. Stabilization 1. If an Emergency Medical Condition exists, medical treatment, within the capabilities of the staff and facilities routinely available ("Capacity"), will be provided to stabilize the individual prior to consideration of discharge, admission or transfer...Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis...b. Psychiatric patients are stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others. Such patients must be given Crisis hotline information at discharge. c. Substance abuse patients (who presented as dangerous to self or others) are considered to be stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others".

Review of the hospital's job description for the psychiatric mental health nurse practitioner revealed "works under the direct supervision of a Medical Staff member (s) of (Name of hospital) for the medical acts performed."

1. Closed DED medical record review from Hospital A of Patient #4 revealed a [AGE] year old patient presenting to the DED on 09/16/2013 at 2200 for a chief complaint of altered mental status. Record review revealed the patient arrived via ambulance after being found lying on the road. Record review revealed law enforcement officer told the Triage nurse they had spoken with the patient's mother and the mother suspected heroin abuse. Record review revealed patient #4 was an acuity level of 2, (emergent) and ESI level of 2. Review of the triage documentation revealed the patient had received Narcan (medication to reverse the affects of narcotics) intravenously prior to arriving at the hospital. Record review revealed the patient had a history of substance abuse, anxiety, paranoid schizophrenia and post-traumatic stress disorder. Review of the MSE (Medical Screening Examination) at 2200 performed by the DED physician (MD #1) revealed the patient presented with altered mental status with an unknown onset. Further review of the MSE revealed the patient was "obviously intoxicated, level of consciousness: uncooperative. Psychiatric: Judgement impaired by intoxication. Record review revealed the patient used cocaine and alcohol 3 to 5 times per week. Record review revealed vital signs at triage were heart rate 77, respiratory rate 17 and blood pressure 114/78. Record review revealed the patient had "garbled words, imprecise slurred" speech and unsteady gait. Review of the record revealed a CAT Scan of the head was completed showing "no evidence of acute intracranial pathology". Record review revealed X-rays were completed of the patients' left hand revealing no fractures and of the chest showing normal findings. Review of nursing documentation on 09/17/2013 at 0335 revealed the patient "remains somewhat drowsy, easily arousible, denies taking any drugs, admits to ETOH (alcohol) earlier and denies SI/HI (suicidal/homicidal ideation's)." Review of the labs revealed the ETOH level was 94.1 ( High per the range) on 09/17/2013 at 0049 and positive for cannabis. Record review revealed documentation by nursing staff on 09/17/2013 at 0407 the patient had talked with someone about picking her up and the "MD agrees to discharge if and when transport arrives." Review of the DED physician documentation at 0547 revealed the patient's condition was improved and the patient was discharged . Record review revealed no documentation of a psychiatric assessment of the patient prior to discharge.

Closed DED medical record review from Hospital B revealed Patient #4 was DOA (dead on arrival) to the DED on 09/19/2013 at 1635.

Telephone interview on 12/30/2015 at 1445 with the County's Register of Deeds Office revealed the death certificate for Patient #4 read, "Cause of Death: Amitriptyline (anti-depressant) Toxicity. Other: Depression, PTSD (post-traumatic stress disorder). Manner of Death: Suicide".

Review of the hospital's census for the behavioral health unit revealed the census for 09/16/2013 was 32. Interview on 12/30/2015 at 1100 revealed the unit is at capacity with 32 patients.

Interview on 12/30/2015 at 1350 with Hospital A's DED Medical Director (MD #2) revealed behavioral health patients are seen initially by the DED physician and a psychiatric consult is obtained if the physician is unable to determine if the patient is a danger to self or others. Interview revealed the medical director started at Hospital A in December 2013 and did not have knowledge of Patient #4.

The hospital's failure posed an immediate and serious threat to Patient #4's health and safety by failure to provide within the hospital's capabilities, for further appropriate stabilization for patient #4, who had a emergent psychiatric medical condition.

Review on 12/30/2015 of an EMTALA "Action Plan" and supporting documentation revealed the following corrective actions implemented by hospital staff prior to the on-site EMTALA investigation survey:

Immediately after the September 2013 survey and before the December 2015 survey (both of which resulted from the same September 2013 complaint) and prior to the receipt of the December 2015 survey statement of deficiencies, a Hospital task force (1) reviewed EMTALA policies, (2) addressed EMTALA training and (3) implemented monitoring
to ensure compliance.

Specifically, the Chief Executive Officer (CEO) organized an interdisciplinary task force comprised of the Chief Nursing Officer (CNO), Associate Chief Nursing Officer (ACNO), Chief Medical Officer (CMO), VP of Quality and Patient Safety (Physician), Director of Quality/Performance Improvement, Accreditation/Regulatory Coordinator, Director of ED, Director of Behavioral Health Services, the Medical Director of Emergency
Services and outside expert EMTALA legal counsel to address and mitigate concerns identified during the surveys.

The Task Force reviewed the findings related to providing Stabilizing Treatments for Behavioral Health patients and patients with behavioral health concerns, as appropriate. The following actions were taken with effective dates as noted below:

1. Policy PC 210.26 - " EMTALA " (see Exhibit A)
was reviewed in January 2014 and again on 01/31/2016
and was deemed appropriate.

2. Policy PC 210.59 - " EMTALA Medical
Screening and Stabilization, Refusal of Treatment "
(See Exhibit B) was revised. Education was provided
and the policy was made effective 5/1/2014.
The policy was reviewed again in January 2016
and deemed appropriate.

3. Policy ECC 450.22 - " Triage and Admission
Care of Emergency Department Patients "
(See Exhibit C, Section B:#3a) - Was reviewed and
revised in February 2014 to include a process for
utilization of Nursing Assessment Tools for
Identification of Substance Abuse and Behavioral
Health concerns. The policy was reviewed again
in January 2016 and deemed appropriate.

4. Policy PC 210.01 - " Care for the Behavioral
Health Patient " (see Exhibit D) - Was revised
February 2014 to describe the process for
identification and management of the behavioral
health patient in the ED. The policy was updated
to include comprehensive RN assessment screening
tools for substance abuse, alcohol abuse and suicide
risk for all ED patients (13 years and above). Any
positive screens generate an automatic referral for
a Behavioral Health assessment which will include
a more comprehensive screening to include the
DAST 20 tool (See Exhibit E) by the Behavioral
Health Specialist. The results of the screening
assessment tools are immediately accessible in the
Electronic Health Record for the use of the
responsible Licensed Independent Practitioner.
The RN will also initiate an " ED Triage - Behavioral
Health Protocol " . (See Exhibit F) Completion Date was 02/28/2014.

5. Initiation of ED Triage Mandatory Documentation Tools in our electronic medical record in which a scoring threshold specified by our policy will generate an automatic referral to the Behavioral Health Specialist.
The CAGE-AID Assessment tool (See Exhibit G) is completed on all patients >18 years of age, assessing alcohol use and illegal/prescription drug use for non-medical reasons. Effective April 2014
The CRAFFT Assessment tool (See Exhibit H) is completed on all patients > 13 for having a drug or alcohol related disorder.
Effective April 2014
6. A Physician Power Note template " Psych/Suicide/Drug/ ETOH " was developed and implemented in our electronic health record in February 2014 to assist in relevant documentation of the Behavioral Health patient. (See Exhibit I).
7. In October 2015, a Behavioral Health Service Line Lean Team was initiated due to increased behavioral health patient volumes, to formalize an on-going method to pro-actively evaluate our Behavioral Health Services provided to our patients. The team is focused on the physical environment, policies/procedures, staff training and current evidence-based care.
To improve the accuracy of suicide risk assessment a decision was made to adopt the Columbia-Suicide Severity Rating Scale in March 2016 (See Exhibit J).
Various educational/training efforts have been conducted and completed from January 2014 through present day including:
1. " Emergency Services and EMTALA Training " was provided for Licensed Independent Practitioners 02/15/2014 and RN's and completed by February 15th, 2014 (See Exhibit K) by outside EMTALA expert legal counsel.
2. EMTALA Training video was also added to RN/CNA hospital general orientation agenda in April 2014. (See copy of agenda - Exhibit M)
3. Annual EMTALA training is assigned as part our organization ' s annual compliance module and is assigned to all staff.
4. 2015 ED Provider Training was conducted through the independent ED physician group. Each provider completed the on-line EMTALA Compliance Training Program (See Exhibit O). This education activity is approved for 1.0 AMA PRA Category 1 Credits.
5. In February 2016, additional EMTALA training (See Exhibit K) was provided to Emergency Department/Women ' s Center Registered Nurses and Licensed Independent Practitioners.
6 " Behavioral Health Specialist Training on Assessment of Behavioral Health Patients in the ED " (See Exhibit N) was provided and completed in February 2014.
7. " Care of the BHS Patient in the ED " (including the CAGE-AID Assessment Tool -
exhibit G and the CRAFFT Assessment Tool - exhibit H) was provided to ED RN's in 2014.
This education was updated with current processes/tools and was provided to ED RN
staff March 31, 2016 through April 10, 2016. (See Exhibit L).
8. Columbia-Suicide Severity Rating Scale (see Exhibit J) education was conducted in the
January 2016 and February 2016 ED Staff Meetings.
A minimum of 70 ED patient records (which is statistically valid for a population size
of > 500 cases) will be audited per month to assess compliance with the identification of patients with behavioral concerns. The monitors will include compliance with RN assessments/ Behavioral Health Specialist assessments and Provider documentation of substance abuse and/or psychiatric concerns. The audits (See Exhibit P)will be conducted by the ED Manager/designee and the Director of Behavioral Health Services/designee.
Monthly audits will be conducted for a minimum of 3 months or greater until an average of 90% compliance is achieved and maintained 4 consecutive months.
Results will be reported to the Corporate Officers Group and the Board Quality Leadership Council on a monthly basis. Deficiencies will be reported by the appropriate Manager/Director to the Chief Nursing Officer, Chief Medical Officer and Vice President for Quality and Patient Safety, as indicated for intervention. Continued deficiencies by any specific individual will result in a disciplinary process.

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