HospitalInspections.org

Based on review of the medical records, interview and confirmation of facility staff and review of facility policies and procedures it was determined that the facility failed to provide an appropriate medical screening to all patients. This affected 3 of the 8 suicidal ideation and/or overdose records reviewed. (Patients #29, 34, and 35). The facility failed to ensure that patients are given the option of being admitted to the hospital instead of being transferred to an outside acute care hospital. This affected 7 of 8 patients who were transferred within the previous six months. (Patient #55, 56, 57, 58, 59, 60, and 61). The sample size included 30 medical record reviews.

Findings include:

1. Review of the medical record for Patient #29 revealed that the patient presented to the Emergency Department (ED) by way of the local fire department on 06/01/10 at 12:39 AM. The squad report stated that the patient's mother called 911 because the patient had contacted his/her mother stating that he/she took all of his/her pills. When the fire department arrived on the scene the patient denied any suicidal ideation. After arriving at the ED the patient still denied suicidal ideation, but admitted to drinking 4 beers. Patient #29 was evaluated by the physician at 1:05 AM and it was documented that the patient was a difficult historian and was upset situationally, but had no homicidal or suicidal ideation. At 3:29 AM the patient was reassessed by the nurse and confessed to taking 20 tablets of Stratera 25 mg (medication used for Attention deficit disorder), but did not give a reason for the ingestion. Nursing staff contacted poison control for instruction and then monitored the patient for 4 hours per the recommendation of poison control. The patient was discharged home without a psychiatric evaluation at 5:55 AM., however the patient was encouraged to follow up with a crisis team if needed and be seen at the local free clinic in two days.
At 8:19 AM, the same day, Patient #29 returned to the ED stating that she was released that AM from the ED. During this ED visit the patient admitted that he/she took all her medicines on Sunday night and that these medicines included; a narcotic anxiety medication, medication for attention deficit disorder, an aspirin based pain medication, a medication used for cough, and acetaminophen. There was no documented evidence of how much of each medication that the patient had ingested. During this return visit he/she was now complaining of feeling weak and shaky. Review of the physician's documentation stated that the patient still continues to have intermittent thoughts of suicide. The patient was transferred to the VA for further evaluation with a diagnosis of dizziness and once the patient is medically stable he/she will undergo a psychiatric evaluation.
2. Review of the medical record for Patient #34 revealed the patient presented to the ED on 04/29/10 at 11:48 AM by personal vehicle. Review of the documentation during triage, noted the patient stated that he/she had accidentally ingested a whole week's worth of medications on Tuesday. The patient denied suicidal ideation and didn't remember taking the medications or why he/she took them. The patient had a history of depression and schizophrenia. Review of the physician's assessment revealed that the patient stated he/she was seen at a counselor's office that morning and didn't feel he/she was suicidal or homicidal. There was no documentation that the physician contacted the counselor to verify these findings. According to documentation, the patient was hearing voices and had been was cutting on him/herself for three weeks. Review of the physician's documentation noted that the overdose was accidental with no suicidal intent and that during an interview with patient #34's mother, she voiced that she feels the patient is "okay and not suicidal". The patient was discharged home without a psychiatric evaluation.

3. Review of the medical record for Patient #35 revealed the patient presented to the ED on 04/08/10 at 9:45 PM by his/her personal vehicle. Patient #35 had a history of bipolar disorder and schizophrenia. Review of the documentation completed during triage at 9:46 PM, revealed the patient stated that he/she had been out of medications for two weeks and is currently living at group home. Patient #35 was also documented as stating that he/she started walking from a group home, couldn't remember where the group home was, and was experiencing paranoid thoughts and hearing voices. Further review of documentation noted the patient stated that he/she had a plan to use poison to commit suicide with either antifreeze or bleach, but had no means of purchasing either at that time. Review of the physician's note timed at 1:42 AM, noted that they (facility) received a call back from the Crisis team and that earlier that day the patient was seen at another local hospital where he/she was evaluated by a counselor prior to coming to this ED. It was noted that the patient was from a group home in Lorain, Ohio and the Crisis team planned on sending a cab to get Patient #35 around 7:00 AM and would arrange bus transportation back to Lorain. On 04/09/10 at 7:15 AM patient left the ED, by cab, without a psychiatric evaluation.

The facility's policy entitled "Suicide Risk Assessment and Interventions in an Acute Care Setting" was reviewed on 06/01/10. This policy stated that all patients receiving any treatment in any inpatient, outpatient or other practice setting with a diagnosis of an emotional or behavioral disorder will be screened for risk of suicide, regardless of the assessment by an outside mental health agency. If a patient is identified to be at risk for suicide, a referral will be made to a behavioral health professional.

Interview of Staff R on 6/4/10 at 2:00 PM revealed a psychiatrist (staff KK) was available for consult in the emergency department.

A review of the leadership team meeting minutes conducted on 06/03/10, revealed that during the meeting conducted on 01/07/10, a comment was made that the suicide policy is "stupid".


The above findings were confirmed with Staff W on 06/03/10 at 11:20 AM.


6. Review of the medical record for Patient #55 revealed the patient presented to the ED on 05/02/10 at 7:15 PM by the local fire department. The patient complained of right shoulder pain and a sudden onset of weakness. The patient has a history of diabetes, hypertension, stroke and prostate cancer. During the visit to the ED, the patient received lab work, imaging studies and an EKG (electrocardiograph, a test that looks at the rhythm of the heart to monitor its function). Review of the attending physician's documentation revealed that Patient #55was diagnosed with low blood pressure, low potassium, kidney failure, weakness and a low blood platelet count. The patient was transferred to a Veterans Administration (VA) Hospital at Wade Park. The record did include a Physicians Certificate for Transfer with the benefits for the transfer listed as the "VA system" and the risks for the transfer listed as "transport". The consent to transfer was signed by the patient. The reason for the initiation of the transfer was listed as "payor directed". The patient was transferred by squad at 1:52 AM with a cardiac monitor and oxygen.

7. Review of the medical record for Patient #56 revealed the patient presented to the ED on 02/21/10 at 11:34 AM by his/her personal vehicle. The patient has a history of chronic respiratory disease, hypertension and gastric ulcers. Documentation noted the patient was triaged as a level 2 (semi-urgent) and complained of a productive cough and pain above the stomach. The patient's oxygen level at triage was 87% on 3 liters of oxygen (normal is 96-100% on room air). During the ED visit the patient underwent testing for lab work, imaging and an EKG. The patient also received medications and a breathing treatment. The patient's diagnostic findings were documented as acute pneumonia, low potassium and an abnormality of the EKG. At 3:52 PM the physician's documentation states that the plan of care was discussed with the patient, the patient is aware that his/her insurance is not accepted here, and that he/she will have to go to Mercy Hospital. The Physicians Certificate for Transfer listed the benefit for transfer as the patient's insurance will be accepted and the risks for transfer were listed as motor vehicle accident and the risk that the patient's condition may worsen during transport. Review of nursing documentation listed the reason for transport to another acute care hospital as "payor directed". The patient was transferred by squad at 4:25 PM with a cardiac monitor and oxygen.

8. Review of the medical record for Patient #57 revealed that the patient presented to the ED on 12/31/09 at 5:59 AM by way of the local emergency squad. Patient #57 had a history of seizure disorder and diabetes. This patient was transported to the ED due to an episode in which he/she passed out resulting in a fall. During the ED visit the patient underwent imaging studies and an EKG. At 8:15 AM the physician's documentation revealed that his/her recommendation is to admit the patient to the hospital due the episode that caused the patient to pass out. Review of nursing documentation revealed that at 8:36 AM the nurse noted that due to the patient's insurance the patient will be transferred to Aultman hospital. At 9:04 AM an addendum was written to the physician's notes which stated that the after the chart was signed and locked, registration informed the physician that the patient's insurance will not cover admission to the hospital (Affinity Medical Center) and that he "must" be transferred to hospital A. The nursing documentation stated that Patient #57's transfer was initiated as per "Payor Direction". At 08:41 AM the patient left the ED by squad with an intravenous line and a heart monitor to be transferred to another acute care hospital. There was no documented evidence found in the medical record that the patient consented to the transfer.

9. Review of the medical record for Patient #58 revealed the patient presented to the ED on 12/21/09 at 3:48 AM by way of the local emergency squad. Patient #58 had a history of anxiety, arthritis, hypertension and stomach problems. At 3:41 AM Patient #58 stated that he/she fell on the way to the bathroom, felt dizzy and almost passed out. Review of the documentation at the time of triage revealed the patient experienced bleeding from the rectum and the nose. During the ED visit the patient underwent imaging studies, lab work and an EKG. The patient was diagnosed with an acute lower gastrointestinal bleed, dizziness, weakness and a cut to his/her forehead. The Physicians Certificate of Transfer stated that the benefits for the patient to be transferred were the need for a gastroenterology consult (physician who specializes in diseases and conditions of the digestive system) and because the patient's insurance dictates. The risks for transfer to the patient was the potential to be involved in a motor vehicle accident during transport to the receiving hospital. Review of nursing documentation revealed that at 6:45 AM Patient #58 was transferred to Hospital A with the reason listed as initiation of transfer is "Payor Directed". At 6:45 AM Patient #58 was transferred to another acute care hospital by squad with a cardiac monitor.

A review of the current physician roster conducted on 06/04/10 revealed that there are six physicians currently associated with the hospital who specialize in gastroenterology. A list of endoscopy procedures was requested and received. The list revealed a total of 12 endoscopy procedures that are preformed on the hospital campus.

10. Review of the medical record for Patient #59 revealed the patient presented to the ED on 12/04/09 at 1:17 PM by personal vehicle with shortness of breath. Patient #59 had a history of chronic respiratory disease and diabetes. During the initial physician exam at 1:17 PM it was determined that the patient was in severe respiratory distress. Throughout the ED visit the patient underwent testing for lab work, imaging studies and an EKG. Review of documentation written by the attending physican at 3:13 PM stated that after the patient was admitted, it was discovered that the patients insurance was not accepted at AMC (Affinity Medical Center). A review of the registration data was conducted and revealed that the patient had Medicaid HMO. The patient was given the option of transfer to either hospital A or B. A review of the nursing documentation listed the reason of the initiation of the transfer as "payor directed" . The Physicians Certificate of Transfer document listed the benefits for the transfer as in-patient care and insurance and the risks for transfer was traffic. At 5:15 PM Patient #59 was transferred to another acute care hospital by squad with a cardiac monitor, oxygen and an intravenous line.

11. Review of patient #60's medical record on 6/3/10 revealed this patient presented to the facility's emergency department on 4/24/10 at 10:49 AM with complaints of chest pain. The patient had laboratory tests, an electrocardiogram, and was placed on oxygen. According to the Nurse Documentation record on 4/24/10 at 2:37 PM the patient was to be transferred to another (hospital A) per the patient's primary physician's request who was on staff at this hospital. The physician was a cardiologist at hospital A and had accepted the patient for admission. The scope of service at this facility revealed this facility had a cardiology program and cardiologists. The patient was transferred to hospital A by ambulance with a heart monitor and oxygen in place. There was no documentation that the patient was deemed stable by the emergency physician. Review of the Physicians Certificate for Transfer record revealed the transfer was based on insurance reasons, stating that the risk for transfer was traffic. The patient signed consent to transfer at 2:10 PM. There was no documentation the patient requested transfer due to insurance reasons.


Interview of staff #R on 6/4/10 at 10:00 AM revealed the patient was responsible for the cost of the ambulance used for transfer to another hospital.

12. Review of patient #61's medical record on 6/3/10 revealed this patient presented to the facility's emergency department on 2/09/10 at 7:48 AM with complaints of nausea, vomiting, diarrhea and seeing double. The patient was to be admitted to a hospital medical bed at 9:55 AM. Physician documentation at 10:55 AM revealed "Pt insurance will not allow him to be admitted here, will transfer to Hospital A" Patient is refusing transfer by ambulance" Review of nursing documentation on 2/09/10 at 11:11 AM revealed the patient left the department at 11:00 AM. Transferred disposition: TRANS-hospital A. Transfer was initiated for: PAYOR DIRECTED STABLE. Review of the Physician's Certificate for Transfer revealed the transfer was based on the need for admission, and "insurance will not let him stay".


On 06/03/10 at 5:05 PM two surveyors discussed multiple ED records with Staff N and Staff W.




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