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.

ABILENE BEHAVIORAL HEALTH LLC 4225 WOODS PLACE ABILENE, TX March 22, 2013
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of the facility log, staff interview, email communication, and patient intake documentation, the facility failed to maintain a central log including each individual presenting for emergency treatment.

Findings were:

Review of the facility "MOT [Memorandum of Transfer] Log" for January 2013 revealed the facility failed to include the arrival or transfer of Patient #2, who presented at Acadia Abilene the evening of 1/28/13 and was transferred via ambulance to a higher level of care (a general hospital) after reporting that she ingested 8-10 Klonopin. There was no documented evidence of a central log including each individual presenting for emergency emergency treatment provided to the surveyors, despite requests on 3/20/13 and 3/21/13.

There was no documented evidence of a clinical record for Patient #2 provided to the surveyors on 3/19/13 at Acadia Abilene (psychiatric hospital), as Patient #2 was transferred from Acadia Abilene to a medical hospital (Hospital A) for an emergency medical condition and "not admitted " to Acadia Abilene. An undated "Patient Registration Information" form for Patient #2 was provided to the surveyors in reference to this complaint. "Hearing voices telling me to OD" was handwritten in response to "Why are you here today?" on the undated "Patient Registration Information" form for Patient #2, which was signed by Patient #2.

A Memorandum of Transfer (MOT) document by Acadia Abilene for Patient #2 on 1/28/13 at 2200. The handwritten diagnosis on the form was "altered thoughts, command hallucinations, [illegible] OD [overdose]". In the space on the form of the physician's signature were the handwritten words, "TORB Dr. [name of physician]" [telephone order read back]. There was no physician signature on the form. Per the MOT, Patient #2 was transferred to Hospital A.

Review of facility Incident Report Form for Patient #2 dated 1/28/13 at 21:30 stated that Patient #2 was a "non-patient" and was "waiting to be assessed" in the "assessment area". The summary of event stated, "Pt reportedly took pills in assessment area while waiting to be assessed (8-10 Klonopin)."

Review of the facility "Call Record" document for Patient #2 provided by Staff #4 on 3/19/13, entered by the Admissions Counselor on 1/28/13 at 1655, stated:
"Pt having command hallucintions (sic) to take all of her meds.
f/u - pt reportedly took 8-10 pills of klonopin while waiting to be assessed in the admissions area. Pt was taken by ambulance to Hospital A ER."

Review of email communication by Staff #4 dated 1/30/13 at 5:29 pm stated, in part, "[Patient #2] stated she waited for hours for an assessment (per the timeline below 3.25 hours and never was assessed) ....
19:11 [Patient #2] arrives ...
22:30 Ambulance arrives to take [Patient #2]
22:36 Ambulance personnel leave with [Patient #2] ...
From my understanding she was never assessed, she reported she od (sic) while in waiting area."

In an interview conducted on 3/19/13 in the conference room with Staff #2, Staff #3, and Staff #4, they stated that Patient #2 came to the facility at "approximately 7:00 or 8:00 pm" on 1/28/13. Patient #2 was "very agitated and verbally speaking out" and was not admitted . While Patient #2 was still in the small room in the vicinity of the main intake waiting area, Acadia staff reported that Patient #2 reached down into her belongings, turned slightly, bent down and made some movements, then turned back around and said "I OD'd" [overdosed]. Patient #2 informed the staff that she had just taken 8-10 Klonopin. Patient #2 still had not been assessed or admitted at the time of this event, and Patient #2 was not seen by a physician.

After Patient #2 told the staff she OD'd, the staff contacted a physician who was not at the facility. The physician gave a telephone order to transfer the patient.

The patient was transferred via ambulance from Acadia Abilene to Hospital A (general hospital) at 2200 on 1/28/13.

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff in the conference room the afternoon of 3/21/2013.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on a review of patient intake documentation, staff interviews, facility reports, ambulance records, and hospital emergency department records, the facility failed to provide an appropriate medical screening examination within the capability of the facility before transferring a patient via ambulance to a higher level of care.

Findings were:

After request by surveyors on 3/19/2013, there was no documented evidence of a clinical record for Patient #2 provided at Acadia Abilene (psychiatric hospital). Patient #2 was transferred from Acadia Abilene to a medical hospital for an emergency medical condition on 1/28/13. An undated "Patient Registration Information" form for Patient #2 was provided to the surveyors in reference to this complaint. "Hearing voices telling me to OD" was handwritten in response to "Why are you here today?" on the undated "Patient Registration Information" form signed by Patient #2.

There was no documented evidence provided to the surveyors of a medical screening examination, patient status, observations of signs or symptoms, vital signs, emergency condition, available history, the emergency medical condition, or any treatment provided for Patient #2 on 1/28/13 at Acadia Abilene.

A Memorandum of Transfer (MOT) form was provided to the surveyors on 3/19/2013 for Patient #2 on 1/28/13 at 2200, indicating a transfer from Acadia Abilene to Hospital A. The handwritten diagnosis on the form was "altered thoughts, command hallucinations, [illegible] OD". In the space on the form of the physician's signature were the handwritten words, "TORB Dr. [name of physician]" (telephone order read back). There was no physician signature on the form. Per the MOT, Patient #2 was transferred to Hospital A. The space on the form for "type of vehicle and company name used" was left blank.

Review of facility Incident Report Form for Patient #2 dated 1/28/13 at 21:30 stated that Patient #2 was a "non-patient" and was "waiting to be assessed" in the "assessment area". The summary of event stated, "Pt reportedly took pills in assessment area while waiting to be assessed (8-10 Klonopin)." Interventions or Treatment Given including "Transfer to Med/Surg Hospital" was left blank. Nursing Assessment, including "Nursing Evaluation and Intervention" was left blank. Reviewed by Supervisor, name, title, signature, date, was left blank. Physician/Practitioner Notified, including Physician name, date, time, and physician response, was left blank. Notification as Applicable including RN Supervisor, Shift Supervisor, Administration, Risk Manager, Director of Nursing, etc. was left blank. Reviewed by Risk Manager to include Incident Level and date reviewed was left blank. The space for the Risk Manager Signature was left blank. Risk Manager Comments/Recommendations was left blank.

Review of the facility "Call Record" document for Patient #2 provided by Staff #4, taken by the Admissions Counselor on 1/28/13 at 1655, stated:
"Pt having command hallucintions (sic) to take all of her meds.
f/u - pt reportedly took 8-10 pills of klonopin while waiting to be assessed in the admissions area. Pt was taken by ambulance to Hospital A."

Review of email communication by Staff #4 dated 1/30/13 at 5:29 pm stated, in part, "[Patient #2] stated she waited for hours for an assessment (per the timeline below 3.25 hours and never was assessed) ....
19:11 [Patient #2] arrives ...
22:30 Ambulance arrives to take [Patient #2]
22:36 Ambulance personnel leave with [Patient #2] ...
From my understanding she was never assessed, she reported she od (sic) while in waiting area."

In an interview conducted on 3/20/13 in the conference room, Staff #2, Staff #3, and Staff #4, stated that Patient #2 came to the facility at "approximately 7:00 or 8:00 pm" on 1/28/13. She was "very agitated and verbally speaking out." Later, Patient #2 did not want to be admitted because it was taking too long and wanted to leave. Patient #2 was not admitted and was not seen by a physician.
While Patient #2 was still in the small room in the vicinity of the main intake waiting area, Acadia staff reported that Patient #2 reached down into her belongings, turned slightly, bent down and made some movements, then turned back around and said "I OD'd" [overdosed]. Patient #2 informed the staff that she had just taken 8-10 Klonopin. Patient #2 still had not been assessed or admitted at the time of this event.
After Patient #2 told the staff she OD'd, the staff contacted the physician who was not at the facility. There was no documented evidence provided to indicate that Patient #2 had a medical screening examination, despite the patient's statement that she overdosed on Klonopin (an anti-anxiety medication). There was no documented evidence of vital signs taken, other signs or symptoms, or the condition of the patient. The physician gave a telephone order to transfer the patient, per the MOT, on which was handwritten, "TORB [physician name]" (telephone order read back) handwritten in the "Physician's Signature" blank. There was no physician signature on the MOT. The patient was transferred via ambulance from Acadia Abilene to Hospital A (general hospital) at 2200 on 1/28/13.

In an interview with Staff #2 and Staff #4 in the conference room on 3/19/13, they confirmed the above and also confirmed that Patient #2 did not have a medical screening examination. Staff #4 confirmed that Patient #2 was never admitted to Acadia Abilene at any point during this event, but was only transferred by Acadia Abilene to the medical hospital per physician telephone order. There was no documented evidence provided to the surveyors that transfer records were sent to the receiving hospital, including the emergency condition at the time of transfer, available history, the emergency medical condition, observations of signs or symptoms, vital signs and/or any treatment provided.

During a tour of the facility on 3/20/13 at 2:10 pm, accompanied by Staff #2 and Staff #5, the admissions/intake area was observed. The room where the patient was located at the time of the overdose was not in the viewing area of the video camera.

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff in the conference room the afternoon of 3/21/2013.

Review of the Ambulance Transfer Notes from MetroCare Services-Abilene obtained from Hospital A on 3/18/13 revealed the following: The ambulance departed Acadia Abilene at 2252 on 1/28/13 with Patient #2. Chief complaint was "hearing voices and took too many clonazipam (sic) .... Called to Acadia Place for a Delta overdose. On arrival, found a 46 y/o female laying (sic) in floor sleeping. On patient contact, she woke up and began talking with EMS. Patient stated that she voluntarily committed herself to Acadia (sic) for hearing voices however after being there for several hours, she decided to take 8-10 0.5mg Clonazipam (sic) around 9pm so she could sleep. Patient taken to ambulance via stretcher .... Assessment of CABC's. IV of NS in the right wrist, cardiac monitoring, positional comfort. Transported to Hospital A ER for further evaluation. Transfer of care made with RN and all signatures obtained without incident and patient remaining alert and oriented entire contact time. Field impression: accidental overdose." The ambulance transfer note was signed by a paramedic, EMT-P.

Review of the Hospital A Emergency Department medical record for Patient #2, date of service 1/28/13, obtained on 3/18/13 from Hospital A revealed no documented evidence of a medical screening examination or assessment provided by Acadia Abilene.

Review of Emergency Physician Record obtained from Hospital A on 3/18/13 revealed the following: "has chief complaint: suicide attempt, self-injury and hearing voices. Associated symptoms included: frustrated, "sitting in admissions in Acadia, people making fun of her ... voices suggest that she hurt herself or someone else, not sleeping." Mechanism: "overdose." List of substances ingested: Klonopin 0.5, number taken 8-10, when taken 9 pm." How did ingestion/other acts come to attention? "told staff at Acadia." Arrived by "ambulance."

Review of Hospital A nursing note of 1/28/13 2319 obtained from Hospital A on 3/18/13 revealed the following: "pt admitted to ER with complaint of taking 8-10 0.5mg Klonopin pta; pt was at Acadia trying to admit herself into higher (sic) care for "hearing voices"; pt states she was in the waiting room at Acadia and there were people making fun of her in the waiting room and so the pt wanted to rest so she decided to take 8-10 of her klonopin; pt denies suicidal or homicidal ideation at present; pt states that she is just wanting to rest; pt states that she has been hearing voices and at times the voices tell her to harm herself or to harm others but pt is usually able to not act upon any of what the voices are telling her as stated by pt; pt is very cooperative and is seeking help at present; pts belongings are taken and pt is left in position of comfort in room 1929 in ER."

In the Hospital A ED record for Patient #2 on 1/28/13 (reviewed by surveyors on 3/18/13 at Hospital A), there was no documentation received from or provided by Acadia Abilene to Hospital A of a medical screening examination, communication of patient status, observations of signs or symptoms, vital signs, emergency condition at the time of transfer, available history, the emergency medical condition, or any treatment provided.