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.

POINCIANA MEDICAL CENTER 325 CYPRESS PKWY KISSIMMEE, FL 34758 March 11, 2015
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure the rights of 2 of 3 sampled patients under a Baker Act involuntary petition were exercised, by not ensuring transfer to a receiving facility (#1), and not documenting rescinding a Baker Act (#3).

Findings:

1. In an interview on 3/10/15 at 5:30 PM, patient #1 related she had been admitted on [DATE] when her family took her to the emergency room (ER). She related she was Baker Acted by an ER physician on 1/19/15, put in a dark room with a sitter, and not allowed to leave until 1/22/15, when the same physician discharged her to her home. She related she did not receive any rights under the Baker Act (BA) rules, did not receive a Writ of Habeas Corpus, and did not see a psychiatrist while she was there.

Review of patient #1's record revealed a diagnosis of suicide attempt/medication overdose. A Baker Act Certificate of Professional Initiating Examination was seen in the record and signed by the physician. "Criteria for diagnosis of Mental Illness/List all mental health diagnoses applicable to this person" was blank and did not contain any information. The form was checked for "Person is unable to determine for himself/herself whether examination is necessary" and "There is substantial likelihood that without care or treatment the person will cause serious bodily harm to self. " The BA form documented the person was examined by the physician at 7 PM on 1/19/15.

The "Request for Involuntary Examination after Stabilization of Emergency Medical Condition" read, "The person arrived at the hospital on [DATE] at 18:36 (6:36 PM), and at 22:59 (10:59 PM) the person's medical condition had stabilized."

Form CF-MH 3101 "Emergency Medical Services' Determination that Person Does Not Meet Involuntary Placement Criteria" in the record read, "As a physician or licensed psychologist and recognized by this hospital as eligible to perform the involuntary examination, I have: Offered voluntary placement of this person OR approved the direct release of this person from the hospital." The areas were left blank and not checked. The form was signed by the physician on 1/22/15 at 8 AM.

Review of the physician progress notes for patient #1 revealed the following:
1/19/15 "Time medically cleared: 2259, for psych evaluation, Condition at discharge: clear for psych facility."
1/20/15 at 6:45 AM - "Patient awaiting psychiatric bed placement. Medically cleared. Baker Act remains in place. No complaints at this time."
1/21/15 at 5:06 AM - "Spoke with patient's psychiatrist earlier, she is going to try to get apt. sooner. In meantime understands mechanism of Baker Act and waiting for psychiatric clearance for discharge."
1/21/15 at 6:11 AM - "Patient awaiting psychiatric bed placement. Medically cleared - Baker Act remains in place. No complaints at this time."
1/21/15 at 6:57 PM - "Patient awaiting psychiatric bed placement. Medically cleared at (2259 1/19/15 per chart) Baker Act remains in place. No complaints at this time."
1/22/15 at 7:54 AM - "Had lengthy discussion with the patient; she has been stable and cooperative since admission; have been unsuccessful in getting a psychiatric evaluation. She states she is not suicidal and really never was. We went over her underlying problems. She promises to return or contact her psychiatrist immediately should she feel despondent. She is going to call her psychiatrist today for follow-up appt. and I had talked with her psychiatrist by phone about 36 hours ago and she was going to get a follow up asap. She also indicated that she had not known the patient to ever be suicidal and felt she was low risk. Accordingly we will rescind the Baker Act and have her follow up with her psychiatrist. The documentation was electronically signed by the physician on 1/22/15 at 0757 (7:57 AM)."

On 1/20/15 and 1/21/15 case management notes read "appropriate documentation faxed to psych facilities, awaiting placement." There was no time documented of when the information was faxed from the facility to the psychiatric receiving facilities. Documentation revealed a case management note that confirmed information was faxed to 29 psychiatric receiving facilities on 1/20/15 and 2 facilities on 1/21/15 with no time documented. There was no further documentation or information available or observed in the record regarding follow-up to the psychiatric referrals that were faxed.

Interview with the Manager of the case management department on 3/11/15 at approximately 4:30 PM revealed there was no further information documented regarding placement follow-up or acceptance to a receiving facility. A discharge disposition on 1/22/15 read, "Discharge disposition-home-Baker Rescinded discharged to home with family."

Review of the facility policy entitled "Baker Act and At Risk Patient" effective date 10/15/14 documented, "The care of patient detained involuntarily under a Baker Act (including Ex Parte) exceeds the scope of service at Poinciana Medical Center. They must be medically stabilized and transported to the appropriate facility according to EMTALA guidelines and they must be observed by trained staff with appropriate competency until their departure." The policy also read, "When the patient is medically cleared, the sending facility has two (2) hours to contact a receiving facility and request transfer of the involuntary patient....One of the following must occur within 12 hours after the patient's attending physician documents that the patients medical condition has stabilized or does not exist: a. The patient must be examined by a designated receiving facility and released; or b. The patient must be transferred to a designated receiving facility in which appropriate medical treatment is available. Within the 72 hour examination period or, if the 72 hours ends on a weekend or holiday, no later than the next working day thereafter, one of the following actions must be taken, based on the individual needs of the patient: a. The patient shall be released, unless he or she is charged with crime in which case the patient shall be returned to the custody of the law enforcement officer; b. A petition for involuntary placement shall be filed in the circuit court when the outpatient or inpatient treatment is deemed necessary."

Patient #1 was Baker Acted by a physician on 1/19/15 at 7 PM, medically cleared at 10:59 PM on 1/19/15, kept at the hospital until 1/22/15, and then discharged to home. The patient did not see a psychiatrist for examination and was not transferred to a psychiatric receiving facility.

2. Patient #3's medical record revealed an [AGE] years old male admitted on [DATE] at 8:55 AM under a Baker Act initiated by law enforcement. The BA form revealed without care/treatment the patient was a danger to himself. A "Request for Involuntary Examination after Stabilization of Emergency Medical Condition" indicated the patient arrived at the hospital on [DATE] at 9 AM, and on 1/01/15 at 12:41 AM, the patient's medical condition had stabilized. The form was signed by a registered nurse (RN) as administrator/designee and current medical problem documented was "aggressive behavior".

The medical record revealed a form entitled "The Centers Hospital Transfer Form (Ocala, Florida)" which read "NOT admitted - Unable to medically manage." Additional information documented the patient's name, age, Alzheimer's dementia, inability to stand or talk, vital signs listed and unable to sign. Not admitted . Documentation revealed the patient was returned to the hospital.

Review of the facility case management notes revealed documentation of 1/01/15 at 2:32 PM Baker Act medically cleared at 12:41 on 1/01/15 - Referrals faxed to psych facilities." There were no additional case management notes found regarding inclusion of notice to family.

An emergency medical condition form signed by the physician documented "patient stable for transfer, receiving facility Centers of Ocala 1/01/15 at 1210. Report given to...."

A discharge summary dated 1/03/15 documented "This is an 86 year old...with a history of advanced dementia, was brought into the emergency room by the police under a Baker Act as he was combative. The patient was cleared and was transferred to a behavioral health facility. At the behavioral health facility, there was concern about incontinence and altered mental status. Hence, the patient was returned back to our hospital. Chest X-ray was done showing an infiltrate suggestive of pneumonia....It is felt that the patient's condition is secondary to advanced dementia rather than a psychiatric etiology. The Baker Act was rescinded. Case was discussed with case management and patient is to be discharged to SNF." No evidence was observed or found that the patient was examined by a psychiatrist following initiation of the BA by law enforcement.

Interview at approximately 7:30 PM on 3/11/15, the CEO and CNO revealed the physician rescinded the patient's BA as documented in the record. No evidence of a BA form to rescind the BA was found in the patient's medical record. Review of the facility policy entitled "Baker Act and At Risk Patients" did not reveal any documentation or direction for the facility to rescind a BA.