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.

DECATUR COUNTY GENERAL HOSPITAL 969 TENNESSEE AVE S PARSONS, TN 38363 April 23, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, document review, medical record review and interviews, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate and ongoing Medical Screening Exam (MSE) to determine if an emergency medical condition existed, and patients requiring transfer were transferred to an appropriate facility for treatment, care and services for 19 of 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19 and 20) sampled patients.

There were no documented Medical Staff By-laws, Rules and Regulations to reflect the Requirements of 489.20 and 489.24.

Refer to 2406 and 2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, document review, medical record review and interview, the hospital failed to ensure an appropriate and ongoing Medical Screening Exam (MSE) was performed, and all patients received treatment and stabilization within the hospital's capacity for 5 of 13 (Patients #4, 7, 13, 17 and 19) patients presenting to the Dedicated Emergency Department (DED) with psychiatric medical conditions.

The hospital failed to ensure the hospital followed its policy for a physican to perform an MSE to determine if an emergency medical condition (EMC) existed for 19 of 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19 and 20) patients presenting to the DED seeking emergency medical attention.

The findings included:

1. Review of the hospital's "Medical Screening Exam [MSE]" policy (Revised 8/10/10), revealed, "It is the policy of [Name of Hospital] to provide emergency medical care to all patients who are in need. In accordance with the EMTALA regulations, all patients presenting to the emergency department requesting treatment will be afforded a medical screening exam (MSE). This exam will be done on each and every patient regardless of insurance, financial status, or ability to pay, and shall be performed before financial data is collected. The exam shall be performed by a physician ...The purpose of the MSE is to determine if an emergency medical condition exists. An emergency medical condition is any condition that might result in death or permanent compromise to an organ or body part in the event stabilizing care is not rendered in a timely manner. MSE should not be confused with triage, which is an evaluation to determine the order in which patients are seen ...After patients have been triaged they will each receive a MSE by a physician ..."

Review of the hospital's "Suicidal Patients" policy revealed, "Purpose: To provide adequate, safe supervision and recognition of suicidal behaviors in-patients exhibiting acute suicidal risks ...the nursing staff will provide and document continuous supervision of the patient. The patient should be attended at all times, including visual supervision during bathroom visits. Supervision of the patient may be provided by the nursing staff or delegated to family members, SWAT [Special Weapons and Tactics] team members, or law enforcement based on the assessed needs of the patient. Patient safety must be maintained ....Utilize restraints only if the patient is a danger to self, staff or others...Eliminate belts, strings or ties from the patient clothing. Ensure that the patient does not have personal medications, knives, or potential weapons in his/her possession ...Obtain Psychiatric Crisis Intervention ...as soon as possible as per MD order ..."

2. Review of the Medical Staff Bylaws and Rules and Regulations (revised September 2015) revealed the only section that addressed the Emergency Department was Section 5 and documented, "Emergency Medical Staff Contracted Category- The emergency staff contracted duties are normally limited to emergency room procedures as per contract agreement. However, any provider who is engaged in the practice of emergency medicine at [Name of Hospital], and who meets all other provisions and requirement for the active staff category may be eligible for active staff status." The Medical Staff Bylaws did not address services or procedures for the emergency department, or expectations for an MSE.

3. Review of the "Hospitalist Delineation of Privileges" signed by Family Nurse Practitioner (FNP) #1 on 8/13/17, the Chief of Staff on 9/12/17 and the Chairman of the Governing Board on 1/23/18, revealed, "...Comprehensive examination, diagnosis & management of:.. Uncomplicated behavioral problems, including crisis intervention, short-term individual counseling for difficulty with interpersonal relationships or adapting to authority & problems related to substance use & abuse ..."

Review of the "Nurse Practitioner/Physician Assistant Emergency Care Competency Checklist" signed by FNP #1 on 8/13/17 and signed by Physician #1 (FNP #1's preceptor) on 9/13/17, revealed competency was verified for the following areas ... "Review's Hospital's policy on EMTALA- specific medical screening examination ...Assesses and initiates appropriate interventions and disposition for suicide risk ..."

Review of the "Hospitalist Delineation of Privileges" signed by FNP #2 (not dated), the Chief of Staff on 12/20/17 and the Chairman of the Governing Board on 2/20/18, revealed, " ...Comprehensive examination , diagnosis & management of:.. Uncomplicated behavioral problems, including crisis intervention, short-term individual counseling for difficulty with interpersonal relationships or adapting to authority & problems related to substance use & abuse ..."

Review of the "Nurse Practitioner/Physician Assistant Emergency Care Checklist" signed by FNP #2 (not dated) and signed by Physician #1(FNP #2's preceptor) on 11/1/17, revealed competency was verified for the following areas ... "Review's Hospital's policy on EMTALA- specific medical screening examination ...Assesses and initiates appropriate interventions and disposition for suicide risk ..."

Review of the "Hospitalist Delineation of Privileges" signed by FNP #3 on 8/2/17, the Chief of Staff on 9/12/17 and no signature from the Chairman of the Governing Board, revealed, " ...Comprehensive examination , diagnosis & management of:.. Uncomplicated behavioral problems, including crisis intervention, short-term individual counseling for difficulty with interpersonal relationships or adapting to authority & problems related to substance use & abuse ..."

Review of the "Nurse Practitioner/Physician Assistant Emergency Care Competency Checklist" signed by FNP #3 on 8/2/17 and signed by Physician #1(FNP #3's preceptor) on 9/13/17, revealed competency was verified for the following areas ... "Review's Hospital's policy on EMTALA- specific medical screening examination ...Assesses and initiates appropriate interventions and disposition for suicide risk ..."

Review of the "Hospitalist Delineation of Privileges" signed by Physician Assistant (PA) #1 on 1/8/18, the Chief of Staff on 1/9/18 and no signature from the Chairman of the Governing Board, revealed, "...Comprehensive examination , diagnosis & management of:.. Uncomplicated behavioral problems, including crisis intervention, short-term individual counseling for difficulty with interpersonal relationships or adapting to authority & problems related to substance use & abuse ..."
There were no documented competencies for PA #1.

Review of the "[Name of Hospital] Emergency Department Nurse Practitioner Protocols", revealed "The following published literature and cloud based references shall serve as reference material and protocol for Emergency Department treatment of patients. These evidence based guidelines will be updated often to reflect the current standards of practice ...The 5 minute Clinical Consult, Standard 2017 25th Edition ...Tarascon Pocket Parmacopoeia, 2016 Deluxe Lab Coat Edition, Epocrates Online at Athenahealth Services ...The Emergency Physician's Guide to prescribing by Disease, 1st Edition ...2017 Physician Desk Reference" The form was signed by Physician #1, FNP #1, #2 and #3. PA #1 did not sign the protocols form.

4. Review of "Emergency Medicine A Comprehensive Study Guide, Sixth Edition" beginning on page 1814 revealed, ...Suicide ...Perhaps the most important part of the assessment of the suicide attempter is a determination of the patients feelings and thoughts at the time of the interview ...Disposition High risk patients whose suicide intent is strong and immediate require immediate psychiatric hospitalization , Moderate risk patients are those who present in a serious suicidal crisis, but who because of positive response to the initial intervention and favorable social support, are not judged to be in immediate danger. hospitalization can often be avoided with such patients, provided practical outpatient treatment can be established immediately. Such determination is often made in concert with a psychiatric consult ...Before discharging a patient a physician must be certain that the patient has a good support system...all patients presenting following a suicide attempt should be carefully assessed. If there is any question about safety of discharging a suicidal patient and psychiatric consultation is not immediately available, the patient should be hospitalized ..."

Review of the Epocrates Online reference for Suicide Risk Management revealed, "...Suicide is the thirteenth leading cause of death worldwide ...Etiology ...The most prevalent mental disorders associated with suicide are major depressive disorder and substance abuse ...Clinical assessment...Suicide risk is an ongoing process in the clinical management of any person who has a mental disorder and must be evaluated/reevaluated under the following circumstances: When a patient presents in crisis to...emergency services...Suicide risk assessment has 4 steps...1. Assessment of the 5 components...ideation, intent, plan, access to lethal means, and history of past suicide attempts 2. Evaluation of suicide risk factors 3. Evaluation of current experience (What's going on?) 4. Identification of targets for intervention. The Tool for Assessment of Suicide Risk (TASR) can be used by the assessing clinician in the clinical setting to help determine the probability of imminent suicide risk. It is a management tool, not a risk assessment tool ...it helps ensure consideration of the most important issues pertaining to suicide risk ...This tool is also provides a good record of the details of the suicide assessment and can be appended to a patients chart or record in any setting...Treatment approach Treatment planning is determined by several factors, including the degree of suicide risk, presence of associated psychiatric condition, and level of social support available...Once the presence of suicide risk is established immediate action should include removing the means for suicide and ensuring the safety of patients and others...Patients who indicate a high degree of suicidal intent, have specific plans, or choose methods with high lethality should be assigned a higher level of risk. Admission to the hospital or observation in a safe place is generally indicated ...Patient who present with psychosis and/ or lack adequate social support should also be admitted to the hospital for continued monitoring ...With Substance abuse ...Patients with alcohol or substance dependence or abuse who are experiencing suicidal ideation, or who have exhibited suicidal behaviors, should be provided with immediate attention ..."

5. Medical record review revealed Patient #4 was a [AGE] year old male who (MDS) dated [DATE] at 11:59 PM with complaints of his throat closing up.

A triage assessment was performed by Registered Nurse (RN) #3 at 12:20 AM who documented, " ...Pt [patient] was hysterical. Could not follow directions for assessment, repeatedly yelled, 'someone gave me something, they're trying to kill me'"

Under the Suicide Screen section the RN documented, "Anxiety, Aggressive behavior, High risk behavior, Periods of excess energy, Delusions, fears someone is tryin [trying] to kill him, schizophrenia...Illicit Drug use: Weekly use Type of Illicit Drug (s) used: Cannabinoids [marijuana]...PD [Police Department] @ [at] BS [bedside] to assist with combative/aggressive behavior. Pt is not oriented to surroundings."

At 12:45 AM PA #1 performed an initial MSE and documented,"pt ran into ER [emergency room ] saying his throat was closing ran back out police ran pt down returned him to ER pt states throat closing can't breathe while screaming people trying to drug him and kill him maybe by poison per GF [girlfriend] pt has HX [history] Schizophrenia and on Haldol but not sure has taken it for couple days he has been gone with brother 2 days showed back up going crazy last time episode like this couple months ago goes weekly to [Name of Counseling Center] ...pt denies SI [Suicidal Ideations] HI [Homicidal Ideations] ...Symptoms Include: Paranoid Delusions, Racing Thoughts, Manic Symptoms...pt very combative running around room thrashing around on bed grabbing BC headache powder [analgesic] drinking red bull [energy drink] ...Mood/Affect: Upset, Agitated ...No respiratory distress ...pt given Haldol IM pt no problems after meds given."

Lab results for Patient #4 revealed he was positive for THC (Marijuana), Amphetamines, Benzodiazepines, and Oxycodone.

There was no documentation Patient #4 was continually monitored by hospital staff to ensure his safety or had an ongoing medical screening examination.

At 7:00 AM Licensed Practical Nurse (LPN) #2 documented, "Patient moved from ER room 2 to ER room 3 for closer supervision at shift change. Patient resting quietly ...called communications for public service from city police. Spoke with [Name of Police] regarding transport to jail for holding d/t [due to] risk for behaviors until [Name of Mental Health Agency #1] can come see him. Informed them of drug screen. All paperwork for [Mental Health Agency#1] given to officer for continuance of care." The patient was discharged to the police department jail for observations at 8:06 AM.

There were no psychiatric interventions documented for Patient #4 prior to his discharge from the hospital DED to the jail.

There was no documentation a physician conducted a MSE in accordance with the hospital's MSE policy to determine if an EMC existed or that the patient received any type of stabilization or treatment.

During an interview in the conference room on 4/19/18 at 3:38 PM, the DON verified it was not appropriate treatment to send Patient #4 to the jail prior to a psychiatric evaluation to determine if an EMC existed.

6. Medical record review revealed Patient #7 was a [AGE] year old male who (MDS) dated [DATE] at 4:30 PM via law enforcement with the chief complaint of drug abuse.

The triage assessment was initiated by EMT-P #1 at 4:40 PM and documented the patient was agitated, confused, hallucinating, had used Methamphetamine and had right and left foot pain.

At 4:55 PM LPN #2 documented the patient had abrasions to the upper and lower extremities.

At 4:59 PM EMT-P #1 documented, "Pt presented into the ER by PD...Pt had on t-shirt, underwear. No socks or shoes...Pt was hand cuffed by PD...Pt was hallucinating...alert and confused...Pt stated he was hearing noises and people were after him with guns...stated someone was going to get him. Pt stated he had done Meth [Methamphetamine]. Pt stated the last time he done Meth was Saturday. Pt stated he didn't do Meth voluntarily today maybe involuntarily. Pt oxygen levels dropped into the 80's and pt was placed on oxygen at 2 lpm [l[liters per minute] by NC [nasal cannula]...PD stated pt was found going up to people houses. PD stated pt had been walking around in the woods in underwear and t-shirt...Pt had laceration to right big toe. Pt had abrasions to right and left feet, right and left arms and hands. Pt had abrasions to face..."

There was no documentation the patient was continuously assessed regarding the use of the handcuffs to ensure they were used safely.

At 5:19 PM PA #1 documented he/she had performed an initial MSE was performed at 4:20 PM. PA #1 documented, "...Chief Complaint: Psychotic Disorders... Auditory hallucinations, Visual Hallucinations, Racing Thoughts...s/s [signs and symptoms] ongoing x [times] years but worse last couple of days after doing meth...not able to recall when ate or sleep...fast pressured speech but with intermitting out burst of cussing and being frightened...Current Condition: Stable..."

Review of the drug screen laboratory results revealed at 5:39 PM Patient #7 had a positive Amphetamine level, normal levels being negative. The patient also had a critical high white blood cell count (WBC) of 26.3, normal levels being 3.9 - 10.6 and an elevated Potassium level of 5.4 millimoles per liter (mmol/L), normal levels being 3.5 - 5.1.

EMT-P #1 documented the following:

At 6:02 PM the patient's oxygen level was normal at 99% with the 2 liters of oxygen being administered.

At 6:14 PM EMT-P #1 documented that a DED nurse spoke via telephone to the patient's mother. The mother reported the patient had Methicillin Resistant Staph Aureus (MRSA) and a Peripherally Inserted Central Catheter (PICC) line in his neck at an unknown time.

At 6:42 PM the patient's oxygen level was 95% on room air without the oxygen.

At 6:43 PM PA #1 documented, "...Final Impression: Paranoid Schizophrenia, Leukocytosis, Hyperkalemia...no source for WBC [white blood count] 26.3...will tx [treat] with Kayexelate...Disposition: Transfer to jail for [Name of Mental Health Agency #1] eval [evaluation]...Diagnosis: Schizophrenia... Hyperkalemia..."

There was no documentation of a psychiatric assessment, stabilization or treatment for Patient #7 prior to his discharge from the hospital DED to the jail for observation.

There was no documentation a physician conducted a MSE in accordance with the facility's MSE policy to determine if an EMC existed or treatment for the patient's elevated Potassium, elevated WBC.

At 6:53 PM EMT-P #1 documented, "Pt was fixing to be given [kayexalate]... Pt then ran out of ER...Pt was caught by Police officers..." The patient was taken to the law enforcement car...taken to jail".

At 7:04 PM EMT-P #1 documented that PA #1 had given the police officer the prescription for the kayexalate to provide to the jail nurse to administer.

During an interview on 4/18/18 at 2:30 PM in the conference room the DON stated PA #1 was unavailable for interview regarding Patient #7.

During an interview on 4/20/18 at 8:30 AM in the conference room the DON stated there was no additional information regarding the patient's oxygen level dropping "into the 80s" requiring oxygen administration and no information related to restraint assessments for the use of handcuffs on Patient #7. There was no documentaion the patient was stabilized prior to being taken to the police department jail for observations.

During an interview on 4/20/18 at 11:00 AM in the conference room the DON stated there was no policy or procedure related to patients presenting to the DED for a MSE while being handcuffed with law enforcement officers.

7. Medical record review revealed Patient #13 was a [AGE] year old male who (MDS) dated [DATE] at 9:39 PM via law enforcement with a chief complaint of suicidal ideations. RN #3 documented the triage assessment was performed at 9:35 PM, which was 4 minutes prior to the patient's arrival. The RN documented, "Pt brought in by PD after calling [Hospital #5] stating if he didn't get help he would slit his throat. Pt states he has had problems for a few months but it has been worse this week".
Under the section titled Begin Suicide Screen the RN documented "No ...".

At 9:50 PM PA #1 performed an initial MSE and documented, "Suicidal ideation, told neighbor wanted to kill his self by cutting his throat the calling [Name of Hospital #5] they called cops pt denies HI [homicidal intentions] ...was taken off Cymbalta seraqual [Seroquel]maybe 2 wks [weeks] or so ago hard keep up with time no other complaints ...Symptoms include: Suicidal Ideation, Suicide Plan, High Risk Behavior, Racing Thoughts ...Onset Mode: 2-3 days not slept in 3-5 days".
Under the section titled the PA documented "Psychiatric: None Reported ...".

At 10:00 PM RN #1 documented, "[Name of Mental Health Agency #1] called for eval [evaluation] Dispatch stated Counselor has been sent to [name of adjacent county] and would come to us next. Pt has stated he wants to leave multiple times in the last half hour."

At 10:11 PM RN #3 documented, "1:1 Observation on admit, PD provided personal [personnel] at bedside ...Appearance: ...Disheveled" Prior to 10:11 PM there was no documentation of 1:1 observation for Patient #13. There was no documentation trained hospital staff provided the 1:1 observation and ongoing monitoring.

Lab results revealed the patient's Alcohol level was 224 mg/dL and he was positive testing for Benzodiazepine.

At 10:22 PM PA #1 documented, "[Name of Mental Health Agency #1 ] called will see in am all counselors busy parsons police will escort pt to jail for obs [observation] till seen by [Name of Mental Health Agency #1 ] in am.." PA #1 documented "Suicidal ideations" as the final diagnosis.

At 11:12 PM Patient #13 was discharged from the hospital's DED in the custody of the police. RN #3 documented, " ...Pt will spend the night in jail under suicide watch and [Name of Mental Health Agency #1] will evaluate in AM. Copy of all pertinent chart items sent with PD personnel. [Name of Mental Health Agency #1] dispatch notified of pts whereabouts for eval in AM".

There was no documentation the patient was continually monitored by hospital staff to ensure his safety or an ongoing MSE was performed to determine if an emergency psychiatric medical condition existed.

There were no documentation the patient received treatment or stabilization prior to his discharge from the hospital DED to the jail for observation.

There was no documentation a physician conducted the MSE in accordance with the hospital's MSE policy to determine if an EMC existed or the patient received treatment and stabilization prior to be transported to the jail for observations.

During an interview in the conference room on 4/18/18 at 8:45 AM LPN #8 verified no psychiatric evaluation or stabilizing treatment was performed at the hospital prior to discharging Patient #13 to the county jail for observations.

During an interview in the conference room on 4/18/18 at 2:20 PM the DON verified it was not appropriate to document the police were providing 1:1 monitoring for suicidal patients in the DED. She stated, "The police are not trained to monitor 1:1 ..."

During an interview in the conference room on 4/18/18 at 3:15 PM the DON verified there was no additional information in the medical record for Patient #13.

8. Medical record review revealed Patient #17 was a [AGE] year old female who (MDS) dated [DATE] at 12:53 PM via ambulance with a chief complaint of overdose of unknown substance. LPN #2 documented the triage assessment was performed at 12:45 PM, 8 minutes prior to the patient's arrival. There was no documented suicide assessment by the nurse.

At 12:45 PM PA #1 documented he/she performed an initial MSE, which was 8 minutes prior to the patient's arrival. The PA documented, "Pt took some meth and xanax this morning not sure how much, denies tylenol asa [aspirin] or any other drugs. Lab results revealed te patient was positive for Amphetamines and Benzodiazepines".

At 1:35 PM LPN #2 documented, "Patient combative and pulled out both iv's [intravenous] and foley catheter. Patient has been cleared medically, however Vs [vital signs] checks needed every 2 hours for 24 hours".

There was no documentation the patient was continually monitored by hospital staff to ensure her safety or an ongoing MSE performed to determine if an EMC existed.

At 5:07 PM PA #1 documented, "Final Impression: polysubstance abuse Current Condition: Stable...DC [discharge] to jail Plan Discussion: Discussed with patient, Discussed with Police Neurochecks q [every] 2 hrs [hours] return pt to ER any changes they [police] verbal understanding...".

There were no documentation of a psychiatric assessment, stabilization or treatment was provided for Patient #17 prior to his discharge from the hospital DED to the jail for observations.

The discharge instructions to perform Nuerochecks were given to police with no evidence of medical training to perform such monitoring.

There was no documentation a physician conducted the MSE in accordance with the hospital's MSE policy to determine if an EMC existed.

During an interview in the conference room on 4/19/18 at 3:29 PM the DON verified that it was not appropriate to send a patient to jail prior to having a psychiatric evaluation or to discharge a patient to the care of police with instructions to perform neurochecks.

9. Medical record review revealed Patient #19 was a [AGE] year old male who (MDS) dated [DATE] at 11:40 PM via law enforcement with a chief complaint of threatening suicide. RN #3 performed a triage assessment at 11:40 PM and documented,"...PD reports during transport pt stated he had taken morphine and wanted to die. Brought to ED for screening...Begin Suicide Screening: Yes...Suicidal ideation, Anxiety, Depressed mood Begin Illicit Drug Use Screen : Yes...Illicit Drug Use: Daily use Type of Illicit Drug(s) Used: Opioid's, Cannabinoids, Hydrocodone Drug Treatment Readiness: Wants treatment, Wants resources, PD to follow up with [Name of Mental Health Agency #1]..."

At 11:55 PM FNP #1 initiated an initial MSE and documented, "...Chief Complaint: Suicidal Ideations..."

There was no documentation the patient was continually monitored by hospital staff to ensure his safety or an ongoing MSE to determine if an EMC existed.

On 1/24/18 at 12:44 AM FNP #1 documented, "Psychiatric: Symptoms include: Feeling Hopeless, Substance Use Concerns, Threatened Suicide..."

Lab results revealed an Alcohol level of 270 mg/dl with low being 0 and high being 10.

On 1/24/18 at 1:11 AM FNP #1 documented, "Oriented to person but intoxicated...Final Impression: Suicidal Ideation, Intoxication Current Condition: Stable...Additional Treatments: Suicide Watch Disposition: Discharge to jail with PD...Discussed with patient, Discussed with officers...Pt is cleared medically and will be taken to jail per PD". The FNP documented the PD would contact Mental Health Agency #1 for a psychiatric assessment for the patient. On 1/24/18 at 1:30 AM Patient #19 was discharged with police to be transported to jail for observations and to receive a psychiatric assessment.

There were documentation of a psychiatric assessment, stabilization or treatment for Patient #19 prior to his discharge from the hospital DED to the jail.

There was no documentation a physician conducted the MSE in accordance with the hospital's MSE policy to determine if an EMC existed.

During an interview in the conference room on 4/19/18 at 3:29 PM the DON verified that it was not appropriate to send a patient to jail prior to having a psychiatric evaluation

10. Medical record review revealed Patient #1 was a [AGE] year old male who (MDS) dated [DATE] at 6:26 PM with the chief complaint of Intoxication. The patient was found face down in the river by a bystander who called 911. A nurse performed a triage assessment at 6:26 AM and documented he was suffering from Post-traumatic Stress Disorder and anxiety.

At 6:45 PM FNP #3 conducted an initial MSE and documented "patient states he is depressed and took a bunch of Xanax ... Psychiatric: Symptoms include: Depression, Substance abuse concerns ...Mood: Depressed lethargic ...Final Impression: Altered Level of Consciousness, Stupor, Medication overuse ..."

Patient #1's lab results revealed he was positive for Marijuana, Cocaine, Opiates, Amphetamines, and Benzodiazepines. The patient was admitted to the hospital's DED for 23 hour observation.

There was no documented evidence the FNP or nurse assessed Patient #1 for suicidal risk or intentional overdose.

There was no documentation a physician conducted the MSE in accordance with the hospital's MSE policy to determine if an EMC existed.

11. Medical record review revealed Patient #3 was a [AGE] year old male who (MDS) dated [DATE] at 5:04 PM via private vehicle with a chief complaint of seeking help to get off drugs. A nurse performed a triage assessment at 5:14 PM and documented he was homeless, had thoughts of harming himself and used Methamphetamine daily. The nurse documented "Protocols initiated for suicide ...1:1 Observation ..."

At 5:20 PM FNP #2 performed an initial MSE and documented the patient had symptoms of suicidal ideation, hopelessness, helplessness, feeling of despair, depressed mood, high risk behavior and drug abuse.

Patient #3 lab results revealed he was was positive for alcohol, Amphetamine, and Benzodiazepine.

At 6:06 PM LPN #1 documented Mental Health Agency #1 had been consulted for an evaluation.

At 6:36 PM a crisis responder from Mental Health Agency #1 initiated a psychiatric evaluation for Patient #3 which resulted in a safety contract.

There was no documentation the patient was continually monitored by hospital staff to ensure his safety or an on-going MSE. There was no documentation the patient received treatment or stabilization while in the DED.

Patient #3 was discharged from the DED at 8:18 PM with information about community resources and the Suicide prevention hotline.

There was no documentation a physician conducted the MSE in accordance with the hospital's MSE policy to determine if a EMC existed.

12. Medical record review revealed Patient #5 was a [AGE] year old female who (MDS) dated [DATE] at 8:19 PM with the chief complaint of suicidal ideations with an onset of 11/14/17. The patient arrived via private vehicle accompanied by foster parents.

The triage assessment was performed by LPN #2 at 8:39 PM and revealed, "Patient told foster parents that she wants to kill herself. She has a plan to use a knife to slice her wrist and bleed out that way no one can stop that like they can with drugs."

At 9:06 PM LPN #2 documented a suicide screen 1:1 supervision began for "Suicidal Ideation, Suicide plan, Depressed mood, Sense of isolation."

At 9:15 PM FNP #1 performed an initial MSE and documented, "Symptoms: Include: Suicidal Ideation, Suicide Plan."

At 9:38 PM LPN #2 documented, " ...[Name of Mental Health Agency #2] Crisis line called for referral ...All information given and a counselor should be here [Hospital DED] within 2 hours."

There was no documentation the patient was continually monitored by hospital staff to ensure her safety or performed an on-going MSE, stabilization or treatment.

On 11/15/17 at 1:37 AM FNP #1 documented, "Diagnosis ...UTI ...Suicidal intent ...Recurrent major depression ...Diagnosis related handout given ...macrobid bid x 10 days ...crisis counsellor [counselor] came to see patient in ED ...Safety contract signed with [name of Mental Health Agency #2]. Will return home with foster parents ..."

The patient was discharged home on 11/15/17 at 1:46 AM.

There was no documentation a physician conducted a MSE in accordance with the facility's MSE policy to determine if a EMC existed.

13. Medical record review revealed Patient #6 was a [AGE] year old female who (MDS) dated [DATE] at 3:55 PM via private vehicle with the chief complaint of suicidal ideation.

The triage assessment was performed by LPN #1 at 4:25 PM and revealed, "Patient here for [Name of Mental Health Agency #1] evaluation...attempt was made to kill herself. Patient states she attempted to shoot herself but the gun jammed. Patient has extensive psychiatric history, several attempts made of suicide in the past...appears intoxicated, unsteady gate [gait], slurred speech, admits to drinking 6 shots of liqour [liquor] today after being sober for 2 years. 1:1 supervision [suicide watch] performed..."

At 4:48 PM RN #1 documented, "...states that she [patient] seen a psych yesterday and they told her she was like a tangled fishing line that would never get untangled."

Review of the alcohol and drug screen laboratory results revealed at 4:42 PM Patient #6 had a high alcohol level of 224 milligrams per deciliter (mg/dl), normal levels being 0-10 and was positive for opiates.

At 5:41 PM LPN #1 documented, "Patient attempted to take pills and put in her pocket, 2 tabs out, noticed, removed pills from hand, identified as Tylenol #3 [narcotic pain medication]. Removed personal belongings from patient, checked pockets, 1:1 supervision continues. Physician made aware."

At 5:47 PM the LPN also documented the patient was to be admitted for observation.

There was no documentation a physician conducted a MSE in accordance with the facility's MSE policy to determine if an EMC existed.

There was no documentation the patient was continually monitored by hospital staff to ensure her safety or an ongoing MSE performed to determine if an EMC existed.

At 7:07 PM LPN #1 documented, "...purse locked up in pharmacy as patient made another attempt to gain acces
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the hospital failed to ensure all patients were stabilized and safely transferred to an appropriate healthcare facility for treatment with a physician's certification for the need of the transfer for 6 of 13 (Patient #4, 6, 7, 13, 17 and 19) sampled patients who presented to the hospital's dedicated emergency department (DED) with psychiatric medical conditions or issues and 1 of 7 (Patient #10) sampled patients who presented to the DED with medical conditions.

The findings included:

1. Review of the facility's "Transfer" policy revealed, " ...Purpose: To ensure that the patient receives the best available care following initial treatment before transferring the patient ...
Policy...Transfer of Patient Without Emergency Medical Condition: Once the emergency care and services have been provided and the patient deemed stable, the patient may be transferred for a non-medical reason only if the following conditions have first been met...The transferring physician has notified a physician at the receiving hospital and has obtained both the physicans ' s [physician ' s] consent to the transfer and the receiving hospital ' s confirmation that the patient meets the hospital ' s admission criteria relating to the appropriate bed, personnel, and equipment necessary to treat the patient ...
The records transferred shall include a "Patient Transfer Record" signed by the transferring physician and containing relevant information pertaining to the patient ' s condition and treatment. The patient being transferred will be provided with appropriate medical care, including qualified personnel and appropriate equipment, throughout the transfer process ...
If the patient is in active labor or has an emergency medical condition, the patient may not be transferred unless the following next two conditions are met:
The patient or the patient ' s legal representative requests the transfer, after being fully informed of the risks and possible benefits involved and of the alternatives to transfer: or
The physician has signed a certification that, based upon the information available at the time, the medical benefits reasonably expected from the provision of emergency medical treatment at another facility outweigh the increased risks to the individual ' s medical condition.
When the transfer is made at the request of the patient or the patient ' s legal representative, the "Consent for Transfer" will be signed ...
Transfer of Stable Individual: Physician determines and documents individual is stable. Obtain written consent from individual or individual ' s designee for transfer. Obtain and document receiving physician. If on transfer to other facilities, obtain and document confirmation with receiving facility ' s staff, preferably RN [Registered Nurse] to RN ...
Transfer of Unstable Patient: Physician determines risks and benefits of transfer. Physician informs patient of risks and benefits of being transferred. Obtain written consent for transfer or refusal from individual or individual designee for transfer. Obtain and document receiving physician. On transfer to private facilities, obtain and document confirmation with receiving facility ' s staff, preferably RN to RN. Complete "Patient Transfer Record." Arrange for appropriate transfer."

2. Medical record review revealed Patient #4 was a [AGE] year old male who (MDS) dated [DATE] at 11:59 PM with the chief complaint of his throat closing up.

A triage assessment was performed by Registered Nurse (RN) #3 at 12:20 AM who documented the patient was hysterical and thought someone was trying to kill him.

Under the Suicide Screen section the RN documented, the patient had anxiety, aggressive behavior, high risk behavior, periods of excess energy, delusions, and fears. The patient reported weekly drug use of marijuana. The nurse documented the police were at the bedside due to combative and aggressive behaviors.

At 12:45 AM Physican Assistant (PA) #1 performed an initial Medical Screening Exam (MSE) and documented, the patient had tried to run from the DED but was retrieved by police. He documented the patient continued to complain that his throat was closing up and that people were trying to kill him. The patient's girlfriend reported he had a history of Schizophrenia and took Haldol. PA #1 documented symptoms of paranoid delusions, racing thoughts and manic symptoms. The patient was given IV Haldol and calmed down.

Lab results for Patient #4 revealed he was positive for Marijuana, Amphetamines, Benzodiazepines, and Oxycodone.

At 7:00 AM Licensed Practical Nurse (LPN) #2 documented, the local police department was contacted to transport the patient to the jail due to risk for behaviors until Mental Health Agency #1 could come perform a psychiatric evaluation. The patient was discharged to the police department jail for observations at 8:06 AM.

There was no documentation the transfer was conducted in accordance with the facility transfer policy, the patient was stabilized prior to transfer, and the physician certified the patient could be transferred safely by law enforcement or the patient transferred to a healthcare facility to receive care and treatment for an identified psychiatric medical condition/issue.

3. Medical record review revealed Patient #6 was a [AGE] year old who (MDS) dated [DATE] at 3:55 PM with the chief complaint of Suicidal Ideation.

The triage assessment was performed by Licensed Practical Nurse (LPN) #1 at 4:07 PM and revealed the patient had attempted to shoot herself but the gun jammed. The patient had an extensive psychiatric history with several suicide attempts in the past. The patient had an unsteady gait, slurred speech and admitted to drinking 6 shots of liquor after being sober for 2 years. LPN #1 documented 1:1 supervision (suicide watch) was initiated.

At 4:18 PM Family Nurse Practitioner (FNP) #2 performed and initial MSE and documented the patient had Suicidal Ideations and was intoxicated.

The FNP documented the patient had symptoms of depression, tearfulness, hopelessness, suicidal planning and slurred speech.

Patient #6's alcohol and drug screen laboratory results revealed a high alcohol level of 224 milligrams per deciliter (mg/dl), normal levels being 0-10 and was positive for opiates.

At 7:48 PM FNP #2 ordered for the patient to be kept at the hospital as an outpatient for 23 hour observations.

Review of the Mental Health Agency Crisis Assessment revealed the crisis psychiatric assessment was performed the following day on 4/5/18 at 11:30 AM. The assessment revealed the patient was unable to contract for safety and the patient was subject to involuntary admission to a psychiatric facility.

Review of the Patient Progress Notes dated 4/5/18 revealed at 5:50 PM Mental Health Agency #1 reported that Hospital #3 had accepted the patient at their inpatient behavioral psychiatric unit.

At 7:14 PM the progress notes revealed, "Patient exited building...hands cuffed in front of body with law enforcement escort..."

Review of the Patient Transfer Form dated 4/5/18 revealed, "...Method of Transport: Law Enforcement...Referring Physician: [Name of PA #1]...Reason for Transport: Psychiatric Consultation...Family/SO Notified of Transport" Yes by telephone PER LAW ENFORCEMENT...Pt Stable..."

There was no documentation the transfer was conducted in accordance with the facility transfer policy and no documentation of a family member signature consenting to and acknowledging the transfer, and the physician certified the patient could be transferred safely by law enforcement.

4. Medical record review revealed Patient #7 was a [AGE] year old male who (MDS) dated [DATE] at 4:30 PM via law enforcement with the chief complaint of drug abuse.

The triage assessment was initiated by EMT-P #1 at 4:40 PM and documented the patient was agitated, confused, hallucinating, had used Methamphetamine and had right and left foot pain.

At 4:59 PM EMT-P #1 documented, the patient presented wearing only a t-shirt and underwear with the police department and was in hand cuffs. The patient reported hearing noises and felt people with guns were after him. He reported that he had used Methamphetamines but was not sure if it was voluntary or involuntary. The patient had abrasions and cuts from walking in the woods with no shoes prior to arrival.

At 4:20 PM. PA #1 performed an initial MSE and documented, the patient had auditory and visual hallucinations and racing thoughts,which were worsened by his recent drug use.

Review of the drug screen laboratory results revealed at 5:39 PM Patient #7 was positive for Amphetamine had a critical high white blood cell count and elevated Potassium level of 5.4

At 6:43 PM PA #1 documented a diagnosis of Paranoid Schizophrenia, Leukocytosis, Hyperkalemia with plans to treat the elevated potassium with medication, when the patient ran out of the DED. The patient was discharged from the hospital DED with police who were given instructions on the administration of the medication. PA #1 documented the transfer of Patient #7 to the jail to wait a psychiatric evaluation by Mental Health Agency #1.

There was no documentation the transfer was conducted in accordance with the facility transfer policy, the patient was stabilized prior to transfer, and the physician certified the patient could be transferred safely by law enforcement or the patient transferred to a healthcare facility to receive care and treatment for an identified psychiatric medical condition/issue.

5. Medical record review revealed Patient #13 was a [AGE] year old male who (MDS) dated [DATE] at 9:39 PM via law enforcement with a chief complaint of suicidal ideations. RN #3 documented the triage assessment was performed at 9:35 PM, which was 4 minutes prior to the patient's arrival. The RN documented, the patient had been brought in by the police after calling a psychiatric hospital and threatening suicide with a plan.

At 9:50 PM PA #1 performed an initial MSE and documented the patient had Suicidal Ideations and had reported to a neighbor he wanted to kill himself by cutting his throat. The patient reported recent antidepressant and antipsychotic medication changes. PA #1 documented the symptoms suicidal ideation with a plan, high risk behavior with racing thoughts and loss of sleep.
Under the section titled the PA documented "Psychiatric: None Reported ...".

At 10:00 PM RN #1 documented, "[Name of Mental Health Agency #1] called for eval [evaluation] Dispatch stated Counselor has been sent to [name of adjacent county] and would come to us next. Pt has stated he wants to leave multiple times in the last half hour."

At 10:11 PM RN #3 documented 1:1 Observation was being provided by the police department personnel.

Lab results revealed the patient's Alcohol level was 224 mg/dL and he tested positive for Benzodiazepine.

At 10:22 PM PA #1 documented, the counselor form Mental Health Agency #1 would see the patient the following morning because all counselors were busy and that police would escort the patient to the jail for observation. The discharge diagnosis was "Suicidal Ideations"

At 11:12 PM Patient #13 was discharged from the hospital's DED in the custody of the police. RN #3 documented, "...Pt will spend the night in jail under suicide watch and [Name of Mental Health Agency #1] will evaluate in AM... "

During an interview in the conference room on 4/18/18 at 8:45 AM LPN #8 verified no psychiatric evaluation or stabilizing treatment was performed at the hospital prior to discharging Patient #13 to the county jail for observations.

During an interview in the conference room on 4/18/18 at 3:15 PM the DON verified there was no additional information in the medical record for Patient #13.

There was no documentation the transfer was conducted in accordance with the facility transfer policy, the patient was stabilized prior to transfer, the physician certified the patient could be transferred safely by law enforcement or the patient transferred to a healthcare facility to receive care and treatment for an identified psychiatric medical condition/issue.

6. Medical record review revealed Patient #17 was a [AGE] year old female who (MDS) dated [DATE] at 12:53 PM via ambulance with a chief complaint of overdose of unknown substance. LPN #2 documented the triage assessment was performed at 12:45 PM, 8 minutes prior to the patient's arrival. There was no documented suicide assessment by the nurse.

At 12:45 PM PA #1 documented he performed an initial MSE, which was 8 minutes prior to the patient's arrival. PA #1 documented the patient took Methamphetamine and Xanax prior to arrival but denied any other drugs.

Lab results revealed the patient was positive for Amphetamines and Benzodiazepines.

At 1:35 PM LPN #2 documented, the Patient was combative and had pulled out both her intravenous lines and foley catheter. She further documented the patient had been cleared medically, however vital signs checks were needed every 2 hours for 24 hours

At 5:07 PM PA #1 documented a discharge diagnosis of polysubstance abuse and that the patient was in stable condition. PA #1 documented the plan was to discharge the patient to the jail and required neurochecks every 2 hours, which would be performed at the jail.

During an interview in the conference room on 4/19/18 at 3:29 PM the DON verified that it was not appropriate to send a patient to jail prior to having a psychiatric evaluation or to discharge a patient to the care of police with instructions to perform neurochecks.

There was no documentation the transfer was conducted in accordance with the facility transfer policy, the patient was stabilized prior to transfer, the physician certified the patient could be transferred safely by law enforcement or the patient transferred to a healthcare facility to receive care and treatment for an identified psychiatric medical condition/issue.

7. Medical record review revealed Patient #19 was a [AGE] year old male who (MDS) dated [DATE] at 11:40 PM via law enforcement with a chief complaint of threatening suicide. RN #3 performed a triage assessment at 11:40 PM and documented, the patient had taken morphine and wanted to die. The Nurse initiated suicide screening questions and documented the patient had suicidal ideations, anxiety and depressed mood. The patient reported daily use of Opioids, Marijuana and Hydrocodone

At 11:55 PM FNP #1 initiated an initial MSE and documented, the chief complaint as Suicidal Ideations.

On 1/24/18 at 12:44 AM FNP #1 documented, "Psychiatric: Symptoms include: Feeling Hopeless, Substance Use Concerns, Threatened Suicide..."

Lab results revealed an Alcohol level of 270 mg/dl with low being 0 and high being 10.

On 1/24/18 at 1:11 AM FNP #1 documented the patient was intoxicated with a final diagnosis of Suicidal Ideation and Intoxication in stable condition.
FNP #1 documented," ...Suicide Watch Disposition: Discharge to jail with PD...Discussed with patient, Discussed with officers...Pt is cleared medically and will be taken to jail per PD".

The FNP documented the PD would contact Mental Health Agency #1 for a psychiatric assessment for the patient. On 1/24/18 at 1:30 AM Patient #19 was discharged with police to be transported to jail for observations and to receive a psychiatric assessment.

During an interview in the conference room on 4/19/18 at 3:29 PM the DON verified that it was not appropriate to send a patient to jail prior to having a psychiatric evaluation

There was no documentation the transfer was conducted in accordance with the facility transfer policy, the patient was stabilized prior to transfer, the physician certified the patient could be transferred safely by law enforcement or the patient transferred to a healthcare facility to receive care and treatment for an identified psychiatric

8. Medical record review revealed Patient #10 was [AGE] years old and (MDS) dated [DATE] at 10:25 AM via private vehicle accompanied by her mother with the chief complaint of Abdominal Pain.

The triage assessment performed by LPN #2 at 10:39 AM revealed the patient was moaning and had a pain level of 8 on a scale of 0-10 with 0 being no pain and 10 being the worst pain.

At 10:45 AM by PA #1 performed an initial MSE and documented the patient had sharp stabbing pain in the abdomen that radiated to the back. The patient had a history of Pancreatitis and Mononucleosis and had received treatment at 2 children's hospitals since January 2018. The patient was administered an Opioid Analgesic for pain. PA #1 ordered for the patient to be transferred to a children's hospital.

LPN #2 documented at 1:58 PM, "Communications notified of emergency transfer to [Name of Hospital #2]." The EMS arrived at 2:23 PM to transfer the patient to Hospital #2.

LPN #2 documented at 2:30 PM, "...Transferring Physician: [Name of PA #1]...Via: Ambulance...Accompanied By: Paramedic/EMS...Reason for transfer: Provider has determined risk would be reduced by patient being transferred...Patient requires services which are not available at the transferring hospital...Receiving Physician: [Name of physician at Hospital #2]...Condition: Stable...Medical Risks: Worsening of conditions or death if you stay here., There is always risk of traffic delay/accidents resulting in condition deterioration...Criteria Attained: Patient stabilized, Appropriate transportation for transfer, Receiving facility accepts transfer, Adequate equipment, Receiving facility has adequate space and qualified personnel..."

LPN #2 documented the report was called to a nurse at receiving hospital, the patient was transferred with cardiac monitoring and pulse oximeter with a copy of the patient's medical record..."

Review of the forms completed for the transfer were titled with the name of Hospital #1.

There was no documentation the transfer was conducted by a physician in accordance with the facility's policy. The form was signed by the patient's mother giving consent to transfer. There was no documentation the consent to transfer included the risks or the benefits of the transfer.