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.
| TEXAS HEALTH PRESBYTERIAN HOSPITAL PLANO | 6200 W PARKER RD PLANO, TX 75093 | Jan. 28, 2015 |
| VIOLATION: COMPLIANCE WITH 489.24 | Tag No: A2400 | |
| Based on interview and record review, Hospital A did not comply with 489.24 (e) (1)-(2). in that the hospital failed to provide a social work evaluation for possible transfer to a psychiatric hospital prior to discharging of 1 of 1 patient (Patient #20) to police custody on 1/20/15. Patient #20 was taken to Hospital B by police and admitted to Hospital B on 01/20/15 with the diagnoses of Major Depressive Disorder (MDD). Hospital A did not initiate a transfer with Hospital B to meet Patient #20's psychiatric needs. Findings included: Patient #20 with a police officer presented in the Emergency Department (ED) of Hospital A on 1/20/15 for "intentional ingestion" of 30 pills "Xanax." Attending physician's (Physician #6) History and Physical indicated Patient #20 had access to a gun. Physician #6 ordered a social worker consultation at 12:26 AM for possible transfer to a psychiatric facility. Patient #20 was medically discharged to police custody at 2:07 AM without being seen by a social worker and/or clinician (1 hour and 41 minutes after the order was made). Patient #20 had no "MAT (Mobile Assessment Team-Crisis Clinician)" evaluation for transfer to another hospital. Patient #20's medical record indicated a late entry by a nurse on 1/20/15 at 3:25 AM "Received call from (Hospital B) requesting a copy of Pt's chart, Received authorization to release...faxed patient care summary to (fax number of Hospital B). " The Medical Record (MR) from Hospital B indicated Patient #20 presented to Hospital B on 01/20/15 at 2:39 AM. The 2:42 AM triage assessment indicated the admission was involuntary with "APOWW (Peace Officer Application for Emergency Detention Without Warrant)" from the police. The notes reflected: "Tell me why you came here to the hospital today: Per APOWW patient took OD (overdose) on 30 Xanax. Patient was cleared discharged from (Hospital A) to police." Patient #20 was admitted to Hospital B for MDD (major depressive disorder) on 01/20/15. In an interview with Personnel #1 in the administration conference room of Hospital A on 1/28/15 at 1:55 PM and on 1/29/15 at 11:54 AM via phone: Personnel #1 was asked what the time frame was for a social worker to respond when a physician's order was activated. She replied per policy the social worker and/or clinician must be in the facility in an hour after he or she was informed of the order. Personnel #1 was asked when the social worker was notified of the social worker consult order. Personnel #1 stated there was no documentation in the MR (medical record) about the notification. Personnel #1 was informed that in Patient #20's MR the physician order for social worker consult was made at 12:26 AM. Patient #20 was discharged at 2:07 AM to police custody. After 1 hour and 41 minutes, from the time of the order to patient discharge, no social worker and/or clinician visited Patient #20. Personnel #1 agreed. In a phone interview with Physician #6 from Hospital A on 1/30/15 at 1:36 PM, he was asked if Patient #20 needed to be transferred to a psychiatric facility. He replied "I do believe he needed psychiatric help. He had access to a gun and he took 30 pills of Xanax." Physician #6 explained that a social worker consult was ordered. The social worker and/or the clinician was responsible for expediting patient transfers. Physician #6 was asked if a social worker saw the patient prior to discharge. He replied "no." "Mobile Assessment Policies" issued 2/2014 required "Provide timely and appropriate assessments in all...facilities ...When called; clinician will return call within 15 minutes and arrive location within 60 minutes of assessment call time." |
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| VIOLATION: APPROPRIATE TRANSFER | Tag No: A2409 | |
| Based on interview and record review, Hospital A did not provide an appropriate transfer for 1 of 1 patient (Patient #20) who presented in the Emergency Department (ED) on 1/20/15, in that a social worker did not respond to Physician #6's order for a social worker consult for a possible transfer of Patient #20 to a psychiatric facility. Patient #20 was discharged to police custody and taken to Hospital B without Hospital A's involvement in the transfer until after Hospital A was contacted by Hospital B for the medical record information. Patient #20 was admitted to Hospital B on 01/20/15 with MDD (major depressive disorder). Findings included: Patient #20 with a police officer presented in the Emergency Department (ED) of Hospital A on 1/20/15 for "intentional ingestion" of 30 pills "Xanax" and alcohol intoxication. The attending physician's (Physician #6) History and Physical at 12:25 AM indicated Patient #20 had access to a gun. At 12:26 AM Physician #6 ordered a social worker consultation. Patient #20 was medically cleared and discharged to police custody at 2:07 AM without being seen by a social worker and/or clinician. Patient #20 stayed one hour and 41 minutes in the ED after Physician #6 ordered a social worker consultation through the "MAT (Mobile Assessment Team-Crisis Clinician)." Patient #20's medical record indicated a late entry by a nurse on 1/20/15 at 3:25 AM that included: "Received call from (Hospital B) requesting a copy of Pt's chart, Received authorization to release...faxed patient care summary to (fax number of Hospital B)." The Medical Record (MR) from Hospital B indicated Patient #20 presented to Hospital B on 01/20/15 at 2:39 AM. The 2:42 AM triage assessment indicated the admission was involuntary with "APOWW (Peace Officer Application for Emergency Detention Without Warrant)" from the police. The notes reflected: "Tell me why you came here to the hospital today: Per APOWW patient took OD (overdose) on 30 Xanax. Patient was cleared discharged from (Hospital A) to police." Patient #20 was admitted to Hospital B for MDD (major depressive disorder) on 01/20/15. In an interview with Personnel #2 in the administration conference room of Hospital A on 1/28/15 at approximately 1:00 PM and on 1/29/15 at approximately 2:15 PM via phone call: Personnel #2 was asked if the ED had 24 hour social worker service. She replied they have a social worker that worked during the weekday. During the week nights and weekends, the facility had a "MAT" team. The MAT team covered the facility and other sister facilities. Personnel #2 was asked to verify the activation of the MAT clinician on 1/20/15 for Patient #20. She confirmed it was at 12:26 AM. Personnel #2 confirmed there was no documentation as to when the MAT clinician was informed about the physician's order. In a phone interview with Physician #6 from Hospital A on 1/30/15 at 1:36 PM, he was asked if Patient #20 needed to be transferred to a psychiatric facility. He replied "I do believe he needed psychiatric help. He had access to a gun and he took 30 pills of Xanax." Physician #6 explained that the social worker consult was ordered and that the social worker or clinician was responsible for expediting patient transfers. Physician #6 was asked if a social worker saw Patient #20 prior to discharge. He replied "no." Physician #6 was asked if he knew where the police officer was taking Patient #20. He replied "no, the patient might be taken to a jail or another facility." "Mobile Assessment Policies" issued 2/2014 required "Provide timely and appropriate assessments in all...facilities ...When called; clinician will return call within 15 minutes and arrive location within 60 minutes of assessment call time." |
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