HospitalInspections.org

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Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility's emergency department (ED) on 08/27/2024 at 5:45 PM via ambulance transport with chief complaints of being in a catatonic state at home. The medical record for the ED visit did not contain an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1.
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Cross reference to Tag A2406
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Based on record review and interview, Facility A failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility's emergency department (ED) on 08/27/2024 at 5:45 PM via ambulance transport with chief complaints of being in a catatonic state at home. The medical record for the ED visit did not contain an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1.
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Findings:
Patient #1's Emergency Medical Services (EMS) Run Sheet Review:
"Received a request for 911 Response (on 08/27/2024 at 4:16 PM) due to a reported catatonia."
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Patient Complaints:
EMS arrived where (Patient #1, a 31-year-old male) was "found in a back bedroom with Ft. Worth Police at the bedside. Given the patient behavior and catatonia, patient was given benzodiazepines to create a safe movement of the patient. (Patient #1) was moved to stretcher, vitals obtained, (Patient #1) moved to the unit for further assessment. (Patient #1) remained catatonic during the movement. Once (Patient #1) was moved to the unit, an EMS Fellow (EMS Staff #3) and report was given to the physicians for their take on the treatment. (Patient #1) became alert and out of the catatonic state, became agitated and removed his IV and all monitoring equipment. The crew exited the unit for safety and the police and doctor began to deescalate. Once calm, (Patient #1) agreed to transport, and (Patient #1) was taken to Facility A with their continuous assessments."
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An exam was completed at 4:36 PM.
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"Versed was given at 4:37 PM"
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At 4:49 PM: Glasgow coma scale (GCS) 3, level of consciousness: unresponsive.
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At 4:50 PM): GCS 15, level of consciousness: alert.
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At 4:51 PM): GCS 15, level of consciousness: alert.
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At 5:02 PM): GCS 15, level of consciousness: alert.
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At 5:21 PM: GCS 15, level of consciousness: alert.
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"Handoff to Facility A (at 5:49 PM)."
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Of note, the patient then became agitated and aggressive. The EMS crew evacuated the ambulance for their safety. Patient #1's aggressive and inappropriate behavior presented a possible risk of harm to self and others and the need for further psychiatric assessment. Facility A failed to provide a psychiatric assessment.
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Patient #1's Detailed Medical Record Review and Timeline at Facility A:
August 27, 2024
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Patient #1, a 31-year-old male, arrived at the Emergency Department (ED) via Emergency Medical Services (EMS) at 5:45 PM with chief complaints of being in a catatonic state at home.
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A triage assessment was initiated by Staff #15 (ED RN) at 5:46 PM. All screenings were completed. Nursing documented:
"ED-SAFE Suicide Screening
Over past 2 wks have you felt down, depressed, hopeless: Yes
Over past 2 wks have you had thoughts of killing yourself?: No
In your lifetime have you ever attempted to kill yourself? When?: Never
ED-SAFE Score: 0
Suicide Screening Level: Negligible"
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Positive toxicology findings documented at 6:02 PM:
Result Value Ref Range___________
Benzodiazepine, Urine Positive (A) Threshold = 200 ng/mL
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The positive result is due to the Versed (a Benzodiazepine) that was given by EMS during his catatonic state. Patient #1 was negative for Amphetamines, Barbiturates, Cannabinoid, Cocaine, Opiates, and Phencyclidine.
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A Medical Screening Exam (MSE) was initiated by Staff #16 (ED Physician) at 6:02 PM. History of Present Illness notes:
" ...(Patient #1) is a 31 y.o. male with has a past medical history of Bipolar 1 disorder (CMS/HCC) and Schizoaffective schizophrenia (CMS/HCC). Brought to the emergency department by ambulance for possible catatonic behavior. Patient (#1) states that he decided to fast like they do in the Bible without food or water or medication and he felt amazing. He (Patient #1) states water makes his stomach hurt, so he drinks milk or sometimes Coca-Cola and eats chocolate because it energizes him. Subsequently, he (Patient #1) began fighting with his wife approximately 5 days ago. He wanted to be left alone ...."
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Assessment Notes by Staff #16:
" ...Psychiatric:
General: sitting upright in bed. Making appropriate eye contact
Mood: Annoyed
Affect: Mildly agitated, frustrated,
Speech: pressured. Borderline tangential (a speech pattern is marked by abrupt changes in conversation and a failure to maintain coherence)
Perception: not responding to internal stimuli
Thought Content: egocentric
Insight: Poor ..."
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The ED physician's (Staff #16's) assessment notes suggested a significant clinical concern. An assessment of Patient #1's judgement was not assessed to determine if the patient was coherent enough to make safe decisions regarding their care. The ED physician (Staff #16) did not document any efforts to reach out to the on-scene physician for collaboration regarding the patient's behavior before and after medication was given. The report of acute catatonia was not addressed due to the on scene physician not being consulted. An EMC was not clearly identified by Staff #16 in his notes.
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Medical Decision Making (MDM) notes by Staff #16:
" ...(Patient #1) is a 31 y.o. male who presents with early mania. Patient is not currently suicidal or homicidal. He retains capacity at this time, stating he has the right not to take his medications and will come back to the psychiatric emergency department in the future if he needs to. He is able to coordinate his own discharge plan, ordering an Uber with the plan to go to a friend's house.
At this time, the patient does not meet criteria for a detention warrant. BHE is in agreement on this point. Although patient is clearly in the beginning of a manic phase, we are unable to detain him against his will as he retains capacity in his not meet suicidal/homicidal criteria. We have implored the patient to go to pec (the psychiatric facility) voluntarily, however he resoundingly refuses. We have encouraged him to return to the emergency department at any time for emergent psychiatric and medical care and have expressed our concerns that he may be an early manic episode.
Patient not amenable at this time ..."
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A "manic phase" was not listed on the final diagnoses. Insufficient information was obtained to determine a safe disposition for Patient #1's clinical condition or to clearly rule out the EMC of acute psychosis with manic symptoms and resolved catatonia posing threat of harm to self/others.
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Clinical Behavioral Health Assessor (CBHA) Notes at 6:48 PM (not a psychiatrist):
" ...(Patient #1) is a 31 y.o. male with self reported (history) of autism, and schizoaffective disorder, bipolar type ...
...(Patient #1) presents to the ED via ambulance due to reported catatonic state. Upon arrival to ED patient alert & oriented and engaging in spontaneous conversation. Upon interview patient
immediately requesting to be discharged. He is anxious, irritable with rapid, slightly pressured speech. Thoughts are organized and future oriented. He goes into detailed explanation that he has been having marital issues, "she disrespects me," and planning to divorce. Today she was annoying him, asking too many questions and he elected to ignore her and would not speak. Wife called 911. Denies SI (suicidal ideation)/HI (homicidal ideation)/AVH (audio or visual hallucinations)/substance abuse. He reports receiving behavioral health treatment since an adolescent with hx (history) of multiple hospitalization in the past. He has private psychiatrist, (name entered), and is prescribed Depakote and Abilify. (Patient #1) admits that he stopped taking his medications 3 days ago and "it's great." He (Patient #1) denies any issues since discontinuing medication. He (Patient #1) is not receptive to behavioral health services today. CBHA educated patient regarding services available in the PEC (psychiatric emergency center) for future reference. He (Patient #1) agreed to follow up with PEC or private psychiatrist as needed.
Declined consent for verbal communication with family. (This meant that Patient #1 did not give his consent for the facility to speak to his wife.) No family contact information in chart or provided by EMS ..."
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" ...Recommendations for Level Of Care:
Patient to discharge. Provided patient with behavioral health community resources ..."
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" ...Current Legal Status:
Legal Status
Is there an active warrantless detention: no
Is Warrantless Detention Being requested?: no ..."
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The behavioral health assessment was insufficient to determine whether Patient #1 retained the capacity for safe decision-making or refusal of care.
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Fentanyl, urine screening documented at 6:53 PM:
Result Value Ref Range___________
Fentanyl, Urine Negative Threshold = 1000 ng/mL
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ED Course Note documented at 7:00 PM:
"(Patient #1) states his wife has control of all their money and the car, so he is planning on calling either the police or his mom when he leaves to have them deal with her."
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ED Notes by Staff #17 (ED RN) documented at 8:21 PM:
"(Patient #1) called wife and wife asked registration if she could speak with RN. Patient does not want wife to speak with RN about medical information. RN did not call wife back or speak to the wife per patients request. Patient was discharged home and given a bus pass by case management."
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