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LIBERTY HOSPITAL 2525 GLENN HENDREN DR LIBERTY, MO 64069 Aug. 8, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy reviews, Emergency Department (ED) Logs, ED Medical Record reviews, Medical Staff Rules and Regulations, Physician On-Call Schedules, and interviews, the facility failed to provide within its capability, stabilizing treatment prior to discharge for one patient (#8) out of 21 sampled ED records selected from the ED Log from February 2018 to August 2018, that presented to the ED seeking care for either a medical or psychiatric condition. The patient presented to the facility's ED per ambulance accompanied by local law enforcement for a psychiatric condition and was discharged into law enforcement's custody prior to stabilizing treatment.

The facility had the capability to stabilize the patient's emergency psychiatric condition, provide on-going assessments to address further signs and symptoms of psychotic episodes and to provide a safe environment.

Refer to A-2407 for additional information.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to provide within its capabilities, stabilizing treatment prior to discharge into law enforcement's custody one discharged patient (#8) that presented to the facility's Emergency Department (ED) seeking care for an Emergency Psychiatric Condition (EPC) out of a sample selected from the facility's ED Log from February 2018 to August 2018. This failed practice had the potential to affect all patients that presented to the ED seeking care and treatment for an EPC. The facility ED saw an average of 2,674 ED cases monthly over the past six months.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 06/24/16 showed directives for staff:
- EMTALA - is a federal law requiring that a hospital with a dedicated emergency department must provide a medical screening examination for an individual who presents to the dedicated emergency department if a medical emergency medical condition exists and provide the necessary stabilizing treatment before discharging or appropriately transferring the patient.
- An "emergency medical condition" is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child.
- Except as set forth below, a patient experiencing an emergency medical condition must be stabilized prior to being discharged or transferred. A patient is considered to be stabilized when the treating physician has determined, with reasonable clinical confidence, that the patient's emergency medical condition has been resolved.
- An Emergency Department physician is responsible for the general care of all patients presenting to the Emergency Department until the patient's private physician, or an on-call physician, assumes that responsibility or the patient is discharged or transferred.
- A patient may be discharged after the emergency medical condition has been resolved or after a determination has been made that the patient is sufficiently stable for discharge. "Stable for discharge" means that continued care, including diagnostic work-up and/or treatment, can be safely performed on an outpatient basis, or later on an inpatient basis, provided the patient is given a plan for appropriate follow-up care with discharge instructions.
- The transfer of a patient shall be carried out by qualified personnel using transportation equipment appropriate for the patient's medical condition.

Review of the facility's "Medical Staff Rules and Regulations," dated 11/01/14, showed that patients with a known or suspected suicidal (thoughts of harming self to include death) intent shall be referred, as soon as possible, to another facility with suitable psychiatric services. When a transfer is not possible, the patient shall be admitted to the Intensive Care Unit or a medical bed close to a Nurse Control Station. The nursing staff will provide companionship, observation, and therapy as needed.

2. Review of Patient #8's discharged ED medical record showed that:
- The patient presented to the facility's ED on 06/28/18 at 9:48 AM per ambulance accompanied by local law enforcement for complaints of abdominal pain.
Triage:
- Date/Time of Triage: 06/28/18 at 9:47 AM;
- Chief Complaint: Hallucinations (an experience involving the apparent perception of something not present); and
- Chief Complaint Quote: Patient states she is here for abdominal pain, possible pregnancy, left wrist and knee pain after being "assaulted" by law enforcement. Law enforcement reporting patient made SI/HI comments (Suicidal Ideations/Homicidal Ideations - thoughts of harming self and/or others). Patient denied. Patient making comments regarding being the "daughter of God" and is chanting prayers. Patient verbally aggressive with aggressive body movements but not making threats towards staff at this time.

History and Present Illness:
- On 06/28/18 at 10:01 AM Staff L, ED Physician, documented that the patient is a [AGE]-year-old female brought in police custody for bizarre behavior and threatening a friend with a hammer. She presents with an unclear psychiatric history. There was an apparent domestic dispute where police were called and at the time they arrived, she was threatening another person with a hammer and attempted to assault them. She was arrested and taken to the police station where she was very agitated, screaming and saying that "I'm the daughter of God!" She complained that the police had apparently assaulted her. The patient is very uncooperative with history questions.
Medical Decision Making:
- Differential Diagnosis: Homicidal ideation, major depression (persistent feelings of sadness and loss of interest), manic depression (bipolar disorder - alternation between high and low mood swings), mood disorder (a psychological disorder characterized by the elevation or lowering of a person's mood), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with extreme reality), schizophrenia (false beliefs, unclear or confused thinking, hearing voices that others do not, reduced social engagement/emotional expression and lack of motivation), suicide attempt, suicide ideation, threatening to others and threatening to self.
- Differential Diagnosis Comment: She appears to be having an acute manic episode, possibly substance-induced, no external signs of trauma other than wrist abrasion on left side, she is comfortable and re-directable. Unclear of her psychiatric history or even her complete medical history unfortunately she is choosing to be uncooperative.
- Treatment Plan: Will get medical clearance labs and urine studies (laboratory tests needed to medically clear the patient so she could be transferred to a psychiatric facility for inpatient care and treatment).
- Problem: Manic state.
Order Summary:
Physician Orders dated 06/28/18 showed the following orders were written for the patient while she was in the ED:
- At 9:52 AM, Suicide/Imminent Risk to Self/Others Precautions;
- At 11:34 AM, Ativan (antianxiety medication used to treat anxiety) 1 milligram (mg) IV (intravenous - a needle placed into a vein used to administer medication, fluids and/or nutrition) push times one;
- At 1:44 PM, Geodon (antipsychotic medication used to treat schizophrenia and bipolar disorder) 20 mg IM (intramuscularly - injection administered into a muscle) times one; and
- At 1:58 PM, Restraints - violent and 1:1 (one staff to one patient face to face) while in restraints.
Physician Orders dated 06/29/18 showed the following orders were written for the patient while she was in the ED:
- At 1:37 AM, Geodon 20mg IM times one;
- At 2:52 AM, Restraints - violent and 1:1 while in restraints;
- At 7:25 AM, Ativan 2mg IM times one and Geodon 10mg IM times one;
- At 2:39 PM, Zyprexa (antipsychotic medication used to treat schizophrenia and bipolar disorder) 10mg PO (oral) times one;
- At 3:21 PM, Zyprexa 10mg IM times one; and
- At 3:26 PM, Benadryl (can be used for as an anti-anxiety to treat anxiety symptoms) 50mg IM times one and Ativan 1mg IM times one.

Review of ED Assessment and Cares/Case Management Notes/Adult Restraint Record/ Mental Health Assessor (MHA) Intake Assessment/Progress Notes/Social Service Notes/ showed that:
Assessment and Cares:
- On 06/28/18 at 9:50 AM, the patient was verbally aggressive but stated no threats. Patient saying prayers/chanting to cast writer's children to "hell", and voiced that she was the daughter of "God". The patient's behavior included being animated, belligerent, response inappropriate for situation, and verbally hostile/aggressive.
- On 06/28/18 at 11:26 AM, the patient attempted to leave the ED room, yelling, "If someone doesn't come in here and do their job and get me out of here in the next 5 minutes, "I'm fucking leaving." Security presence was at bedside. The patient was escorted back into room and verbal de-escalation (use of a calm tone and approach to calm a person that is experiencing agitated/aggressive behavior) techniques being used with patient calming down.
Case Management Note:
- On 06/28/18 at 11:26 AM, the patient attempted to elope (a patient that is physically, mentally, emotionally and/or chemically impaired wanders /or walks away from the facility unsupervised prior to discharge). Security was called and stopped the patient. The patient was given Ativan 1mg times one.
- On 06/28/18 at 1:49 PM, the patient was agitated and cussing. The patient was given Geodon IM and Security at bedside.
- On 06/28/18 at 1:55 PM, the patient aggressively pulled drawers out of the cabinet and threw them across the room. Security intervened and patient was restrained. The patient was placed in 4 point restraints (both arms and legs are restrained preventing free movement), yelling and snarling.
Adult Restraint Record:
- On 06/28/18 at 1:55 PM, the patient was placed into restraint because she was screaming in the room and ripped out the drawers. The patient took the contents in the drawers and threw them across the room. The patient was not re-directable, she is aggressive and uncooperative. Security at patient's bedside. Prior to restraints, the patient was given other options to calm down but continued to act aggressive. At 2:54 PM the patient was released from restraints and was no longer a threat to self/others. The patient's behaviors are controlled through sedation and/or medication.
MHA Intake Assessment:
- On 06/28/18 at 2:33 PM, the MHA's Intake Assessment showed:
- Homicidal/Violence Risk Factors: Violence/threats towards others and previous history of violence;
- Elopement Risk Factors: Legal charges, impulsive, agitated/uncooperative and verbalizing desire/plans to leave;
- Substance Use History: Alcohol and hallucinogens (marijuana);
- Level of Care Determination: Inpatient Acute Care - Behavior which is life threatening, destructive or disabling to self or others;
- Initial Problems Identified/Justified for Level of Care Chosen: Imminent danger to self and acute behavior control needed;
- Mobil Assessment Disposition: Patient remaining in hospital pending placement;
-Disposition: The patient is on hold with local law enforcement for domestic violence charge. She was given Ativan to help her calm down. She is now in mechanical restraints as she has gotten agitated, was pacing and started getting out of control. She appears to be in a manic-state and religiously preoccupied and does not believe she needs treatment. She will need to be involuntary.
Assessment and Cares:
- On 06/28/18 at 5:04 PM, the patient was screaming and stated that she was going home and tried to leave the ED room. Attempts made to de-escalate the patient with Security at bedside.
Adult Restraint Record:
- On 06/29/18 at 1:56 AM, the patient was placed in restraints because she was agitated/restless, had cognitive impairment, at risk for harm, lack of judgement, prevent disruption of care, and prevent harm to self and unable to follow commands. At 3:15 AM the patient was released from restraints.
Assessment and Cares:
- On 06/29/18 at 7:03 AM, the patient became agitated, jumping on the bed and threw her breakfast tray. Security assisted with de-escalation, ED physician at bedside and verbal orders given. The patient consistently stated, "God will get you, fuck you, fuck you, I'm leaving today and you can't stop me."
- On 06/29/18 at 8:47 AM, Precautions: Suicide, homicide/violence toward others and one-on-one provided.
- On 06/29/18 at 12:05 PM, the patient was placed in restraints because she was agitated/restless, had cognitive impairment, at risk for harm, lack of judgement, prevent disruption of care, and prevent harm to self and unable to follow commands. At 2:20 PM, the patient was released from restraints.
- On 06/29/18 at 12:06 PM, the patient attempted to elope from department and became violent with staff. Code White (will be activated when a show of support is determined necessary to de-escalate a threatening situation) called, Geodon administered, spit hood (mesh hood or spit guard is a restraint device intended to prevent someone from spitting or biting) applied and violent restraints re-applied. Patient returned to ED room 9.
Case Management Note:
- On 06/29/18 at 12:24 PM, the patient escaped after using the bathroom in bed 9 (psych safe room in the ED - a room that has been cleared of any objects a patient might use to harm themselves or others), sprinted down the hallway to the doors leading into the hallway going to the parking garage from the ED. The doors were open at the time, but a Security Guard was passing by the hall and saw her running towards him. The patient was tackled by several personnel and brought back to the ED bed 9. The patient was swearing loudly and verbally abusive. The patient assaulted a Security Guard and a Licensed Practical Nurse (LPN). Local law enforcement was called related to this assault. The patient was administered Geodon IM. The MHA has been in touch with the ED secretary twice this morning and actively looking for placement.
Progress Note:
- On 06/29/18 at 1:00 PM, Staff L, ED Physician, documented that the patient is a major flight risk as she attempted to run out of her department and assaulted staff on the way. Multiple security guards and staff to help restrain patient. She was given Geodon 20mg IM and placed in bed 9. Symptoms are improving following Geodon.
Assessment and Cares:
- On 06/29/18 at 3:20 PM, the patient continued to be verbally abusive to staff. The patient called this nurse a "fat cunt" three times and that all staff members could go "fuck" each other in another room and leave her the "fuck" alone. The patient stated that this nurse was a "bitch" this was going to "hell" and stated that maybe you can lose some of that weight when "God" sends you to "hell". The patient moved her head in an up and down motion verbally talked to "God." At 3:21 PM, the patient was agitated and removed her own clothes. She was combative and yelling at staff. She attempted to break the ED room door and window. The ED physician and security are at bedside. The patient refused to take Zyprexa by mouth. Route changed from oral to IM by the ED physician.
Case Management Note:
- On 06/29/18 at 4:44 PM, the MHA stated that placement will not be possible today. Staff D, LMSW, Social Services Supervisor, now involved and she was provided the original affidavits held in the ED so she can present to the court.
Progress Note:
- On 06/29/18 at 5:30 PM, Staff J, ED Physician, documented that he took over care of the patient. Patient is currently in a manic episode. We did receive a court order for the patient to be discharged under care of the Police Department. Patient is not suicidal homicidal. She is manic.
Assessment and Cares:
- On 06/29/18 at 6:39, the patient was discharged into County Sheriff Department custody by court order to be taken to locked psychiatric facility. Discharge instructions and clothing given to law enforcement.
Social Service Note:
- On 06/29/18 at 5:15 PM, Staff D, Licensed Master Social Worker (LMSW), Social Services Supervisor, documented that she received direction from Staff M, Registered Nurse (RN), Chief Nursing Officer (CNO), and Staff N, Risk Management, to proceed with involuntary court ordered mental health petition. Petition paperwork has been completed and five affidavits have been completed by staff and one affidavit from the patient's significant other. Petition paperwork and original affidavits have been submitted to the County Probate Court for Judge's signature and permission for release of patient from the facility's ED to law enforcement custody for likely placement in community mental health facility. The patient was discharged per wheelchair and will be transported by the County Sheriff's auto. Chart will be copied to provide to law enforcement at the time of patient's discharge.
Case Management Note:
- On 06/29/18 at 7:00 PM, Involuntary court ordered mental health petition was approved for the patient; she has been released to law enforcement for transfer. For the best interests of the patient, she needed urgent psychological intervention.
- On 07/01/18 the patient returned to the facility's ED per ambulance with complaints of weakness and headache. The patient was currently on a 96 hour hold at a local inpatient psychiatric facility but escaped from there, reportedly last evening/night. The patient was a 1:1 here from 06/28/18 to 06/29/18 and was exhibiting severe psych symptoms, assaulted some medical personnel, and attempted elopement from this facility. Social Services Manager did secure court order on 06/29/18 for patient to be placed, involuntarily, to psych unit for urgent psych intervention. The patient was discharged to Sheriff's department for placement into any open psych unit appropriate for the level of care the patient requires. She was returned back to the local psychiatric facility that she eloped from per ambulance (the patient returned to the facility's ED within 72 hours after being discharged into law enforcement's custody).

Review of the Application To Court For 96 Hour Detention, Evaluation and Treatment/Rehabilitation undated showed that:
- Staff D, LMSW, Social Services Supervisor, filled out the form.
- Patient #8 is now in the facility's ED #9.
- The applicant (Staff D) has reason to believe that the respondent (Patient #8) is mentally disordered/abuses alcohol or drugs or both as defined by law and presents a likelihood of serious harm to herself or others, and thus is in need of detention, evaluation and treatment/rehabilitation.
- The facts that support the applicant's (Staff D) belief that the respondent (Patient #8) is mentally disordered/abuses alcohol or drugs or both are:
- Patient #8 has been witnessed to be violent, harming staff members of the facility and her significant other.
- Patient #8 is religiously preoccupied and believes she is pregnant.
- Patient #8 has attempted to leave the facility and had to be apprehended and taken down by staff.
- The facts that support the applicant's (Staff D) belief that the respondent (Patient #8) presents likelihood of serious harm are:
- Attempts have been made by Patient #8 to harm her significant other and staff at the facility.
- Patient #8 is displaying psychotic behaviors and aggressive harmful behaviors.
- Patient #8 has also attempted to destroy property of the facility.
- Patient #8's behaviors are not safely able to be managed in an ED.

3. During an interview on 08/08/18 at 10:10 AM, Staff D, LMSW, Social Services Supervisor, stated that:
- The MHA experienced difficulty placing the patient for inpatient psychiatric care/treatment.
- ED staff, Staff M, RN, Chief Nursing Officer, and Staff N, Risk Management, voiced concerns to her about the patient being violent in the ED.
- A patient that was violent would be considered any act of harm to self, staff, visitors, and facility equipment/property.
- After she received the call about the patient being violent in the ED, she went to the ED to see the patient and she visualized one ED staff member that was providing 1:1 observations for the patient with a bandage on her arm and a security guard complained about the patient knocking his glasses off during interactions with her.
- After she had interactions with the ED staff, proceedings were initiated with the County Court to let the judge determine if the patient was going to be released into law enforcement custody.
- The facility petitioned the judge, however; facility staff did not see the final court order and it was considered legal.
- The judge makes the final determination what happens to the patient and the next step would be for the sheriff to serve the court order to the patient, the patient would be hand-cuffed and placed in law enforcement's vehicle and transported to wherever the judge had ordered the patient to go.

During an interview on 08/08/18 at 9:04 AM, Staff C, Registered Nurse (RN), ED Nurse, stated that she was assigned as the primary nurse for the patient for approximately one hour. Staff C stated that the patient was actively delusional and very violent. Staff C stated that the patient would have had a psychiatric evaluation provided by the MHA. Staff C stated that the MHA reported their findings to the ED physician but the assigned nurse caring for the patient might not get a report after the MHA completes their assessment.

During an interview on 08/08/18 at 10:52 AM, Staff E, RN, ED Nurse, stated that he took care of the patient the last couple of hours before her discharge on 06/29/18. Staff E stated that the patient was moved from a regular ED room to ED room 9 - ED's Psych Safe Room because the patient had taken all the drawers out and was jumping up and down on the ED bed.

During an interview on 08/08/18 at 11:14 AM, Staff G, LPN, ED Tech, stated that she assisted in caring for the patient on 06/29/18 and assisted the staff in getting the patient back to the psych safe room. Staff G stated that the patient was running in the ED towards the exit door and the patient had a hospital gown on backwards. Staff G stated that she assisted in holding the patient while restraints were being placed after the patient attempted to elope from the building.

During an interview on 08/08/18 at 1:08 PM, Staff J, ED Physician, stated that he took care of the patient during the last part of her ED visit on 06/29/18. Staff J stated that he did not recall the specifics about this case (Patient #8) and he did not know if the patient was stable for discharge into law enforcement's custody since he could not recall the case or the patient.

During a telephone interview on 08/17/18 at 8:00 AM, Staff O, ED Medical Director, stated that:
- Law enforcement was fatigued from giving assistance to the facility's ED staff and they (law enforcement) either wanted the patient to be returned to jail or to go to a locked psychiatric facility (there was no documentation in the patient's ED medical record that law enforcement was present during the patient's ED stay).
- He did not know who petitioned the judge for a court order to discharge the patient into law enforcement's custody.
- If a patient was being transferred from the facility to another facility and displayed signs and symptoms of self- harm or harm towards others, the patient would be transported per ambulance, however; if the patient was going to jail or had a court order, the patient would be transported per law enforcement vehicle.
- Law enforcement was aware of the patient's condition and was with the patient during her ED visit from 9:48 AM on 06/28/18 to 6:39 PM on 06/29/18 and law enforcement are trained in Crisis Intervention Techniques and had Basic Life Saving training, so the patient would be transported safely while in law enforcement custody.
- If law enforcement had complained that the patient was overmedicated, the facility would have kept the patient in the ED and contacted the judge to give him an update on the patient's condition.
- The facility's process was not to contact the judge for patient placement.
- If facility staff petitioned the judge, that would not be an acceptable process/protocol or practice of the facility for a patient in the ED.
- The facility ED had the capability in keeping a patient in the ED until inpatient psychiatric placement could be found for the patient.
- The facility's ED was responsible to transfer a patient in stable condition with proper communication with the receiving facility.

The facility failed to provide stabilizing treatment within its capabilities prior to discharging Patient #8 into law enforcement's custody. The patient continued to experience a psychiatric emergency condition up to the time she was discharged into law enforcement's custody. The patient continued to display delusional behaviors, required being restrained for violent behaviors, attempted to elope from the ED several times, removed her clothes and jumped up and down on the ED bed, threw her meal tray, and received antipsychotic and antianxiety medications per IM approximately three hours before discharge.