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.

HOLSTON VALLEY MEDICAL CENTER 130 WEST RAVINE ROAD KINGSPORT, TN 37662 Dec. 21, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical record review, facility policy review, review of emergency room Logs, observation, and interview, the facility failed to conspicuously post the required signage, failed to maintain a complete emergency room Log for one patient (#19), and failed to appropriately transfer four patients (#3, #5, #13, and #18) of twenty sampled patients.

The findings included:

Please refer to A-2402 for failing to conspicuously post the required signs.
Please refer to A-2405 for failing to maintain a complete emergency room Log.
Please refer to A-2409 for failing to appropriately transfer.
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on review of facility policy, observation, and interview, the facility failed to conspicuously post signs specifying the rights of individuals with respect to examination and treatment for emergency medical conditions.

The findings included:

Review of facility policy Number last revised in January 2011, revealed, "...must post one or more signs conspicuosly or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area). In general, the sign(s) should be visible from anywhere in the area or a distance of twenty (20) feet, whichever is less..."

Observation on December 17, 2012, at 12:20 p.m., revealed the required sign was not visible on entry through the double doors of the emergency room or on the walls of the waiting area. Continued observation revealed a sign with the required wording posted on a wall behind the nurse's station.

Interview with an Assistant Vice President of Patient Care Services on December 17, 2012, at 12:20 p.m., at the emergency room nurse's station, confirmed the facility failed to conspicuously post the required signs.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility policy, review of Medical and Dental Staff Rules and Regulations, medical record review, and interview, the facility failed to provide an appropriate transfer for four patients (#3, #5, #13, and #18) of four patients reviewed for transfer.

The findings included:

Review of facility EMTALA (Emergency Medical Treatment and Labor Act) policy Number last revised in January 2011, revealed, "...Any transfer of an individual with an emergency medical condition must be initiated either by a written request from the patient...or by a physician order with the appropriate physician certification...must transfer the patient if it has exhausted all of its capabilities in trying to stabilize the patient's emergency medical condition...For purposes of transferring a patient with a psychiatric condition between facilities, the patient is considered to be stable when...is protected and prevented from injuring...self...or others...A stablized patient may be transferred...pursuant to pre-arranged transfer/treatment plans if the following conditions are met...Patient Transfer Order...has been completed by a physician or a qualified medical person in consultation with a physician (physician's counter-signature is required on documentation); the Patient Transfer Order must document stabilization and communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer...A patient whose condition has not been stabilized may be transferred to another facility only in compliance with one of the following two procedures...the individual...requests a transfer...OR 2. A physician has determined that the patient cannot be stablized at the facility due to the unavailability of appropriate medical services. The physician must complete and sign a Patient Transfer Order certifying...the benefits of the transfer to another medical facility outweight the risks...must state the reason(s) for transfer and must contain a summary of the risks associated with the transfer..."

Review of Medical and Dental Staff Rules and Regulations most recently amended September 24, 2012, revealed, "...Psychiatricand /or mental health consultations...may be performed by Psychologists, Master's of Social Work, and Psychological Examiners licensed...and credentialed...under the direct supervision of physician staff members. The attending physician is responsible for providing orders for the patient's safety, acute medical care, stabilization of the patient, and arranging for transfer to an appropriate facility as needed..."


Medical record review revealed Patient #3 presented to the facility's emergency room (ER) on September 22, 2012, at 10:19 a.m.
Medical record review of a triage note dated September 22, 2012, at 10:26 a.m., revealed, "...has suicidal ideation...has exhibited past suicidal behavior...triaged directly to Main ER..." Medical record review of a nurse's note dated September 22, 2012, at 10:26 a.m., revealed, "Security at bedside..."
Medical record review of a History and Physical dated September 22, 2012, at 10:20 a.m., revealed, "...here voluntarily for a psychiatric evaluation..."
Medical record review of a nurse's note dated September 22, 2012, at 10:31 a.m., revealed, "NP/PA (Nurse Practitioner/Physician Assistant)...with patient." Medical record review of a nurse's note dated September 22, 2012, at 12:38 p.m., revealed, "...Crises (Crisis- a mental health provider) requested to evaluate pt (patient)..." Medical record review of a nurse's note dated September 22, 2012, at 3:25 p.m., revealed, " ...Crises (Crisis) here for bedside evaluation." Medical record review of a nurse's note dated September 22, 2012, at 5:55 p.m., revealed, "(Hospital #1) has deferred pt. Pt. will remain here tonight..."
Medical record review of a nurse's note dated September 23, 2012, at 4:06 a.m., revealed, "...Security remains at bedside." Medical record review of a nurse's note dated September 22, 2012, at 7:40 a.m., revealed, "spoke with crisis pt does not ned (need) to be reevaluated by crisis staff no beds at crisis facility ..."
Medical record review of a Certificate of Need for Emergency Involuntary admitted d September 22, 2012, at 2:00 p.m., revealed, "...I am a Qualified Mental Health Professional (QMHP) who has been designated by the...Commissioner as a mandatory pre-screening agent...(Patient #3) is endorsing Suicidal thoughts with a plan to shoot...self...past suicide attempts...There is a likelihood that serious harm could happen if (patient) is not in a secure environment, in patient hospitalization ...Needs in patient hospitalization to get back on medication and to become stabilized...is not able to contract for safety..." Continued review revealed the document was signed by a Licensed Medical Social Worker.
Medical record review of an Physician's Assistant note dated September 23, 2012, at 9:16 a.m., revealed, "Condition at discharge - stable...discussed with ED (Emergency Department) attending physician. Attending physician physically available and saw patient..." Continued review revealed, "To be transferred. Transferred to crisis. Discussed transfer with crisis who accepted transfer."
Medical record review of a nurse's note dated September 23, 2012, at 10:42 a.m., revealed, "crisis staff to ER to eval (evaluate) another pt asked about (Patient #3)...presenting (Patient #3) to (Hospital #2) today..." Medical record review of a nurse's note dated September 23, 2012, at 6:35 p.m., revealed, "...has been deferred by (Hospital #2) ...Pt to stay here...overnight..."
Medical record review of a nurse's note dated September 24, 2012, at 12:52 a.m., revealed, "Security at bedside..." Medical record review of a nurse's note dated September 24, 2012, at 6:55 a.m., revealed, "...Security officers outside room. Pt is in blue crisis gown..." Medical record review of a nurse's note dated September 24, 2012, at 7:35 a.m., revealed, "...are waiting on crisis to reeval (reevaluate) for bed at (Hospital #2) ..."
Medical record review of a Crisis Intervention and Consultation Assessment Form dated September 24, 2012, at 12:06 p.m., revealed, "...has been in ER for two days waiting for placement in a psychiatric hospital...to ED on 9/22/12 @ 10:19 due to suicidal thoughts...was evaluated on 9/22/12 and referred for inpt (inpatient)...but as of now no facility has accepted...for treatment...has demons which tell (patient) to hurt...self, and sometimes...feels like killing...self..."
Medical record review of a Certificate of Need for Emergency Involuntary admitted d September 24, 2012, at 12:06 p.m., revealed, "...I am a...(QMHP)...symptoms are likely to worsen without treatment...cannot contract for safety...requires direct transportation to an admitting psychiatric facility for a second Certificate of Need (CON) examination..." Continued review revealed the form was signed by a Licensed Medical Social Worker.
Medical record review of a Certification of Crisis Service Provider Involvement in the Decision for Inpatient Psychiatric Services dated September 24, 2012, at 1:50 p.m., revealed, "...This form certifies that a Crisis Service Provider was an active participant...for inpatient psychiatric services...at...(Hospital #3)..."
Medical record review of a Technician Note dated September 24, 2012, at 2:27 p.m., revealed, "...has being excepted (been accepted) to (Hospital #4) per Dr..."
Medical record review of a nurse's note dated September 24, 2012, at 4:33 p.m., revealed, "...has been accepted to (Hospital #5) at Greenville...Transport has been requested."
Medical record review of a nurse's note dated September 25, 2012, at 1:49 a.m., revealed, "...Security at BS (bedside)..." Medical record review of a nurse's note dated September 25, 2012, at 8:52 a.m., revealed, "...was transferred to (Hospital #4) ...Patient/caregiver received a copy of the transfer sheet (EMTALA form) which provides detailed information about the transfer ...transferred via law enforcement..."
Medical record review revealed no documentation regarding a physician's order for transfer, physician to physician communication and/or a transfer form.

Medical record review revealed Patient #5 presented to the facility's ER on October 6, 2012, at 3:55 p.m.
Medical record review of a triage note dated October 6, 2012, at 4:41 p.m., revealed, "...Chief complaint Anxiety...Shortness of breath...has 'attacks' 26-30 a day..."
Medical record review of a History and Physical dated October 6, 2012, at 5:46 p.m., revealed, "...recent bizarre behavior...here voluntarily for a psychiatric evaluation...clearly delusional..."
Medical record review of a nurse's note dated October 6, 2012, at 6:00 p.m., revealed, "...requested security to sit with patient."
Medical record review of a Technician Note dated October 6, 2012, at 6:03 p.m., revealed, "crisis called for consult..."
Medical record review of a Physician's Assistant note dated October 6, 2012, at 6:27 p.m., revealed, "To be transferred ...Patient was transferred to (Crisis mental health provider). Discussed transfer with (Crisis mental health provider) who accepted transfer..."
Medical record review of a nurse's note dated October 6, 2012, at 8:05 p.m., revealed, "Crisis has been called to come and eval (evaluate) patient..."
Medical record review of M.D. (Medical Doctor) #1's note dated October 6, 2012, at 10:07 p.m., revealed, "...concur on the final disposition."
Medical record review of a Crisis Intervention and Consultation Assessment Form dated October 6, 2012, at 10:20 p.m., revealed, "...ER staff reports pt present to hospital with shortness of breath, anxiety, delusions...PA (Physician's Assistant) spoke with me after my assessment...reports that pt appears to be very manic, he is concerned for (patient's) safety if (patient) was released...states (M.D. #1)...feels like...needs to get more intense psychiatric help..."
Medical record review of a Certificate of Need for Emergency Involuntary admitted d October 6, 2012, at 11:20 p.m., revealed, "...I am a...(QMHP)...pt delusional...not taking meds (medications)...needs med eval (evaluation), symptom control psychotherapy...pt refuses voluntary tx (treatment). Staff concerned pt a danger to...self and needs intensive psych (psychiatric) tx..."
Medical record review of a nurse's note dated October 7, 2012, at 3:20 a.m., revealed, "(Psychiatric Hospital) accepted ...Admissions confirms acceptance by Dr..."
Medical record review of a nurse's note dated October 7, 2012, at 11:19 p.m., revealed, "...dc (discharge) placed in cruiser..."
Medical record review revealed no documentation regarding a physician's order for transfer, physician to physician communication, or a transfer form.

Medical record review revealed Patient # 13 presented on October 27, 2012, at 8:53 p.m.
Medical record review of a physician order dated October 27, 2012, at 8:59 p.m., revealed, "...Notify Crisis to see patient once Stat (immediately)..."
Medical record review of a triage note dated October 27, 2012, at 9:00 p.m., revealed, "...threatening...danger to self and others ..."
Medical record review of a History and Physical dated October 27, 2012, at 9:00 p.m., revealed, "...Poor historian because: AGGRESSIVE AND UNCOOPERATIVE..."
Medical record review of a physician's note dated October 27, 2012, at 9:37 p.m., revealed, "To be transferred. Patient was transferred to...CRISIS. Discussed transfer with CRISIS who accepted transfer..."
Medical record review of a nurse's note dated October 27, 2012, at 10:15 p.m., revealed, "Spoke with...(Crisis mental health provider) concerning mental health evaluation..."
Medical record review of a nurse's note dated October 28, 2012, at 5:45 a.m., revealed, "called to bedside by security...Pt had removed Crisis Gown...verbally abusive and hostile..."
Medical record review of a Crisis Intervention and Consultation Assessment Form dated October 28, 2012, at 7:15 a.m., revealed, "...combative, aggressive...refusing to cooperate with assessment...Pulled out catheter. Continues to get up and walk around in room naked in full view of staff and other patients ...unable to plan for safety in any manner. Needs INPATIENT INVOLUNTARY hospitalization for stabilization...In acute psychotic state..."
Medical record review of a Certificate of Need for Emergency Involuntary admitted d October 28, 2012, at 7:30 a.m., revealed, "...I am...(QMHP)...danger to self and others...needs secure inpatient treatment for stabilization..." Continued review revealed the form was signed by a Licensed Medical Social Worker.
Medical record review of a nurse's note dated October 28, 2012, at 8:53 p.m., revealed, "...transferred to (Psychiatric Hospital) ..."
Medical record review revealed no documentation regarding a physician's order to transfer the patient, physician to physician communication, or a transfer form.

Medical record review revealed Patient #18 presented on December 5, 2012, at 12:19 a.m.
Medical record review of a triage note dated December 5, 2012, at 12:30 a.m., revealed, "...has been placed under suicide precautions...had shotgun to head threatening to kill self...hx (history) of psych issues..."
Medical record review of a History and Physical dated December 5, 2012, at 12:38 a..m., revealed, "...Has definite suicidal thoughts and has a plan..."
Medical record review of a physician's progress note dated December 5, 2012, at 1:41 a.m., revealed, "Re-evaluation...SI (suicidal ideation). Shotgun plan. Serious...will need admit..."
Medical record review of a Crisis Intervention and Consultation Assessment Form dated December 5, 2012, at 3:05 a.m., revealed, "...Per hospital ER - pt presented to ER on Dec. 05 at (12:19 a.m.) for ME (mental evaluation) after family stopped pt from shotting (shooting) self with shotgun tonight..."
Medical record review of a Certificate of Need for Emergency Involuntary admitted d December 12, 2012, at 3:05 a.m., revealed, "...I am a...(QMHP)...hx (history) inpatient tx (treatment) and in outpatient treatment for Bipolar Disorder...stopped from 'pulling trigger on (loaded) shotgun...hoping no one would stop (patient) from killing self...needs tx/further evaluation in secure environment...danger to self..." Continued review revealed the form was signed by a Licensed Professional Counselor.
Medical record review of a Physician Assistant's note dated December 5, 2012, at 3:43 a.m., revealed,"Disposition decision is to transfer...Discussed transfer with crisis worker who accepted transfer. Condition at discharge - stable."
Medical record review of a nurse's note dated December 5, 2012, at 6:31 a.m., revealed, "Per...(Crisis), pt accepted at (Psychiatric Hospital)..."
Medical record review of a nurse's note dated December 5, 2012, at 7:57 a.m., revealed, "...Transfer to (Psychiatric Hospital). EMTALA not applicable. Given to family member husband. Patient will be transferred via law enforcement...left department..."
Medical record review revealed no documentation regarding a physician's order for transfer of the patient, physician to physician communication or a transfer form.

Interview with Medical Doctor #1 on December 18, 2012, at 1:25 p.m., revealed he did not complete transfer forms for psychiatric patients, and he stated, "With psych transfer I don't talk to a doctor at receiving hospital and don't document risks for psych patients..."
Interview with the Risk Manager on December 18, 2012, at 11:00 a.m., in a Risk Management office, revealed explanation of risks and/or benefits and other transfer documentation was not required for involuntarily committed patients. Continued interview confirmed the facility had inappropriately transferred Patients #3, #5, #13, and #18.