HospitalInspections.org

Based on interviews and medical record reviews, the hospital's Governing Body failed to assure the Administrator provided clear direction to the Administrative Assistant and outpatient clinic staff regarding the Administrator's consideration of "banning" or terminating outpatient clinic services to Patient Identifier # 1 (PI # 1) due to PI # 1's reported hostile and agressive behaviors.

When PI # 1 arrived for his scheduled outpatient clinic visit on 12/29/09, a nurse escorted the patient to the treatment area and obtained his chief complaint and vital signs. While PI # 1 was in the outpatient treatment area, the Outpatient Clinic Director informed PI # 1 that he (PI # 1) had to leave the clinic and secuirty escorted the patient off hospital grounds.

On 1/14/2010, the Hospital Administrator stated an Administrative Assistant, responding to a telephone call from outpatient clinic staff on 12/29/09, told staff that PI # 1 was actually "banned" from the outpatient clinic. According to the Administrator, the Administrative Assistant advised staff because the Assistant overheard discussions by Administration regarding consideration of the termination of outpatient services for PI # 1. However, the Administrator states PI # 1 has not been banned. As a result, the Administrative Assistant acted without confirmation or direction from an Administrator by advising clinic staff PI # 1 was banned from the clinic.
This affected one of ten sampled residents.

Findings Include

December 24, 2008: Pain Clinic MD Note: Referred by Hospital's Medical Director. Patient has problem with chronic low back pain and left knee pain...Patient says Hospital Medical Director wrote prescription for Lortab on 12/2/08. Reports he never filled scripts for Naprosyn, Ultram or Neurontin, but he still has these scripts...Patient spends most of appointment building case for why he should have Lortab...He has not tried other, less problematic or addicting treatment, nonprescirption modalities. Will take off Lortab, refer to Physical Therapy...Encouraged patient to take other non-narcotic prescriptions and give then time to work. Consider repeat MRI later, but exam today is completely benign. Not sure patient can tolerate or benefit from Pain Clinic goals/treatment

During an interview with the CRNP on January 13, 2010 at 10:15 AM, the CRNP said PI # 1 presented for his appointment in December 2009. One of the medical clerks told the CRNP PI # 1 was not to be seen according to direction from the Medical Director's office. "I didn't see him (PI #1) that day." The CRNP talked with the Clinic Director who she reports "took care" of PI # . "All I know is the patient was escorted out." The CRNP reports she did not hear anything while PI # 1 was in the outpatient clinic in December. The CRNP says no one provided an explanation of the reason PI # 1 was not to be seen. According to the CRNP, "Somebody is going to get hurt (referring to PI # 1's behavior)." The nurse says she was frightened after an incident when PI # 1 cursed and yelled at one of the physicians in the clinic. The CRNP identified three physicians who had previously seen PI #1. During PI # 1's initial visit with the CRNP, sometime in November 2009, the patient asked for Lortab and Xanax. The CRNP explained she could not prescribe these medications and she would have to discuss this issue with her supervising physician. PI # 1 said he did not want any prescriptions from the CRNP's supervising physician. PI # 1 asked why he was assigned to a provider who could not prescribe these medications.

The Clinic A Licensed Practical Nurse (LPN) who brought PI # 1 from the waiting area into the outpatient clinic during the patient's December 29th appointment, was interviewed at 11:00 AM on January 13, 2010. According to the LPN, patients are called to the clinic area as soon as an examination room is available. As the LPN was obtaining PI # 1's vital signs, the patient asked the LPN why she was being so sharp with him. The LPN told the patient she was not being sharp with him. It is standard procedure to obtain the patient's vital signs and their chief complaint. The clerks (positioned at the entrance of the clinic) told the LPN that security was coming to get PI # 1 because he was not allowed in the clinic per the Medical Director. PI # 1 had seen the Medical Director earlier that day. The LPN asked the CRNP if she still wanted to see the patient and she said yes. PI # 1 was "smart with the clerks" when leaving the clinic. The LPN defined "smart" as loud. The LPN stated she wished that soneone had told her that PI # 1 was not allowed in the clinic as she would not have brought PI # 1 back in the clinic area.

During an interview with Physician # 1 on January 13, 2010 at 11:25 AM, he stated he last saw PI # 1 approximately two years ago. The physician stated he is accustomed to dealing with frustrated patients, but PI # 1 is aggressive and berated staff and this MD. PI # 1 accused the MD of being a racist and not wanting to deal with the problems that he (patient) wanted to deal with. The physician said it is uncommon for a patient to attack your character. PI # 1 uses intimidation and name calling to get his way. PI # 1 initiated a physician change. This physician did not recall any incident involving PI # 1 in December 2009. According to the physician, many clinic patients are frustrated about their illnesses, loss of job and other problems and this is undestandable. However, PI # 1 is different because he berates the nurses and clerks which is more upsetting that when PI # 1 yelled at me.

During an interview with Medical Clerk # 1 on January 13, 2010 at 1:50 PM, the clerk reports she has not received instructions about action to take if PI # 1 presented to the clinic. The clerk denies telling the CRNP or any other clinic staff that PI #l was not to be seen on 12/29/09.

The Security Officer who responed to a call from Clinic A on December 29, 2009 about PI # 1 was interviewed on January 14, 2010 at 11:00 AM. The officer said he was told by a clerk from Clinic A that a patient "barred" from the hospital needed to be escorted off the premises. The patient said he received a letter from the clinic about this appointment. PI # 1 said he was not aware that he was barred from the clinic. The Clinic Director verified PI # 1's identify and informed the patient he had to leave. PI # 1 voluntarily left the clinic with the officer without incident.

During an interview with the Medical Director/Hospital CEO on January 14, 2010 at 1:25 PM, the Medical Director was asked if PI # 1 is "banned" from Clinic A. According to the Medical Ditector, PI # 1 is not banned from the clinic or hospital. The Director said, "Basically this is false because there is no documentation. The doctors in Clinic A will no longer see the patient." The patient was evaluated by the Pain Clinic Board Certified Pain Management Psychiatrist sometime in 2008. The patient wants Lortab...PI # 1 got angry and came to my office for medicine. The psychiatrist was not comfortable with PI # 1 returning to the pain clinic due to PI# 1's behavior during the evaluation. PI # 1 was referred back to Clinic A (Medicine Clinic).

According to the Medical Director, the hospital has considered not allowing PI #1 to continue as an outpatient. The Admnistrative Assistant heard this discussion and thought PI # 1 had been banned from the Outpatient Clinic. When the clinic staff called Administration on December 29th, the Assistant told staff PI # 1 was banned from the clinic. The Medical Director verified no letter was sent to the patient and the documentation in the medical record is poor. The Medical Director said PI # 1 should not have been escorted off hospital property. "Everybody was reactionary." When asked about PI # 1's current status, the director said PI # 1 is still a patient.

Based on medical record review and staff interviews, the hospital notified PI # 1 that he was not allowed in the clinic during a scheduled outpatient appointment on December 29, 2009. This resulted in PI # 1 being escorted off the property by a security officer. The facility also failed to provide written notice to PI # 1 regarding this decision. This affected one of ten sampled patients.

Findings Include:

Review of Medical Record (Summaries of Outpatient Visits):

August 31, 2006: MD Note: "Asked by Administration to work-in patient. Patient requests Tussionex for cough. Says he was being seen by another physician, but patient dismissed this MD after the doctor "called around." Seeing as general medicine patient today - not specifically referred to pain clinic. He refused to give a urine drug screen. I explained to patient that Tussionex is a narcotic and that I need to evaluate him first and he needs to give a urine specimen. No respiratory distress or cough observed during brief conversation. Patient said he would give a urine specimen, but he has a dental appointment and needs to leave right away. Puzzling to me why patient would have agreed to come here when he knew he had a conflicting appointment. Referred back to Administrator. Suspect drug seeking..."

September 25, 2006: Pain Clinic MD Note:..."Patient now states he is here for Pain Clinic (doesn't have a referral)...Complains of back pain and left knee pain. Do not have records requested from Hospital A in April 2006. Patient says he was diagnosed with Bipolar Disorder in 1997. Patient has a bag of old medicine bottles. Showed me bottles of Lortab and Xanax. Refused to show me the other bottles. Became beligerant and refused to provide additional history and would not allow me to examine him.
Addendum: Seen with Administrator after above encounter. Waited for urine drug screen results: Positive for Benzodiazapines (script) and Methadone (no script) Patient had not told me about this - then admitted taking Methadone from another patient (obtained illegally) Again, refused exam or x-rays."

July 30, 2007: MD note: "Presents to establish PMD. Complains of chronic low back pain greater than five years - etiology unclear. Off all medications for some time...Patient seems unsatisfied with plan. Need to work up etiology of pain discussed. Tolerance and increased dependence on narcotics discussed. Not on any NSAID (Non Steriodal Anti-infammatory Drugs) which would be first line with musculoskeletal back pain...Insomnia: Discussed that Xanax is not a common treatment for insomnia and patient is not currently taking. Will change to Trazadone as needed for sleep..."

October 29, 2007: MD Note: "Presents for follow up for low back pain. Reviewed records from Hospital A including clinic notes... Patient expressed distrust with our facility and unhappiness with current treatment plans. Assured patient we will do our best to ease his pain, but unlikely with chronic pain that he will be pain free.
Assessment/Plan:
1. Insomnia:- Trazadone not helping. Will try Ambien 10 mg at bedtime.
2. Bipolar Disorder: Decrease Trileptal 300 mg one half tab everyday.
3. Chronic Low Back Pain: Repeat MRI (Magnetic Resonance Imaging) Low Back. Opiate Pain Contract today.
4. Hypertension (HTN): BP readings from fire station 130's/70's. Increased blood pressure today (148/93). ? Agitation..."

July 22, 2008: MD Note: "Complains of back and left knee pain...Patient looks hostile; wants to remind me that he requested me..."

November 3, 2008: Certified Registered Nurse Practitioner (CRNP) Note:.."Wants to resume Xanax 2 miligrams (mg) twice per day. Requests referral to Mental Health for counseling. Also wants to have input into his healthcare. Disabled veteran...Reports pain contract was not violated in 2007. Patient needs to complete request for medical records from Hospital A - will facilitate referral to Mental Health. Back Pain/Arthritis: Ultram, Naprosyn and Neurontin. Plan: Urine drug screen, return to clinic in one month."

December 10, 2008: CRNP Note:..."Patient states he did not get the prescription filled that was written by the CRNP because Medicaid will not pay for more than one pain medication. Did get # 60 Lortab from Hospital's Medical Director. Has not slept in over a year. Was seen at another ER October 2008 - two pack and shot."

December 24, 2008: Pain Clinic MD Note: "Referred by Hospital's Medical Director. Patient has problem with chronic low back pain and left knee pain...Patient says Hospital Medical Director wrote prescription for Lortab on 12/2/08. Reports he never filled scripts for Naprosyn, Ultram or Neurontin, but he still has these scripts...Patient spends most of appointment building case for why he should have Lortab...He has not tried other, less problematic or addicting treatment, nonprescirption modalities. Will take off Lortab, refer to Physical Therapy...Encouraged patient to take other non-narcotic prescriptions and give then time to work. Consider repeat MRI later, but exam today is completely benign. Not sure patient can tolerate or benefit from Pain Clinic goals/treatment."

February 9. 2009: CRNP Note:..."Keep appointment with hospital Medical Director regarding complaint related to pain management."

May 11, 2009: CRNP Note:"HTN Follow up...Patient "States dealing with this administration as well as (name of Hospital Medical Director) is causing stressful condition and a feeling of not being treated fairly due to reprisal." No details are documented..."Needs the prescriptions for pain prescribed at our initial visit..."

May 22, 2009: CRNP Note: "Hypertension follow up...Reports he did not attend phyical therapy because patient thought the pain management issue would be resolved by now. Uses the word "killing" to describe back pain today. Patient says "dealing with pain managment issue has an adverse affect on his health. No one in management is accountable for this."
No show to pain clinic 5/6/09.

December 29, 2009 - 9:30 AM: Nurse Note: "Follow up HTN, Diabetes. Complains of back pain, thigh and feet." Vital signs and Accu-check results are documented. There is no other documentation by the CRNP or physician.

During an interview with the Chief Operating Officer (COO) on January 12, 2010 at 3:45 PM, the COO confirmed PI # 1 was last seen in Clinic A on December 29, 2009.

During an interview with the CRNP on January 13, 2010 at 10:15 AM, the CRNP said PI # 1 presented for his appointment in December 2009. One of the medical clerks told the CRNP PI # 1 was not to be seen according to direction from the Medical Director's office. "I didn't see him (PI #1) that day." The CRNP talked with the Clinic Director who she reports "took care" of PI # . "All I know is the patient was escorted out." The CRNP reports she did not hear anything while PI # 1 was in the outpatient clinic in December. The CRNP says no one provided an explanation of the reason PI # 1 was not to be seen. According to the CRNP, "Somebody is going to get hurt (referring to PI # 1's behavior)." The nurse says she was frightened after an incident when PI # 1 cursed and yelled at one of the physicians in the clinic. The CRNP identified three physicians who had previously seen PI #1. During PI # 1's initial visit with the CRNP, sometime in November 2009, the patient asked for Lortab and Xanax. The CRNP explained she could not prescribe these medications and she would have to discuss this issue with her supervising physician. PI # 1 said he did not want any prescriptions from the CRNP's supervising physician. PI # 1 asked why he was assigned to a provider who could not prescribe these medications.

The Clinic A Licensed Practical Nurse (LPN) who brought PI # 1 from the waiting area into the outpatient clinic during the patient's December 29th appointment, was interviewed at 11:00 AM on January 13, 2010. According to the LPN, patients are called to the clinic area as soon as an examination room is available. As the LPN was obtaining PI # 1's vital signs, the patient asked the LPN why she was being so sharp with him. The LPN told the patient she was not being sharp with him. It is standard procedure to obtain the patient's vital signs and their chief complaint. The clerks (positioned at the entrance of the clinic) told the LPN that security was coming to get PI # 1 because he was not allowed in the clinic per the Medical Director. PI # 1 had seen the Medical Director earlier that day. The LPN asked the CRNP if she still wanted to see the patient and she said yes. PI # 1 was "smart with the clerks" when leaving the clinic. The LPN defined "smart" as loud. The LPN stated she wished that soneone had told her that PI # 1 was not allowed in the clinic as she would not have brought PI # 1 back in the clinic area.

During an interview with Physician # 1 on January 13, 2010 at 11:25 AM, he stated he last saw PI # 1 approximately two years ago. The physician stated he is accustomed to dealing with frustrated patients, but PI # 1 is aggressive and berated staff and this MD. PI # 1 accused the MD of being a racist and not wanting to deal with the problems that he (patient) wanted to deal with. The physician said it is uncommon for a patient to attack your character. PI # 1 uses intimidation and name calling to get his way. PI # 1 initiated a physician change. This physician did not recall any incident involving PI # 1 in December 2009. According to the physician, many clinic patients are frustrated about their illnesses, loss of job and other problems and this is undestandable. However, PI # 1 is different because he berates the nurses and clerks which is more upsetting that when PI # 1 yelled at me.

During an interview with Medical Clerk # 1 on January 13, 2010 at 1:50 PM, the clerk reports PI # 1 became upset and asked to speak with the clinic supervisor prior to the December 2009 appointment. PI # 1 was sent to the Oupatient Clinic Director. Prior to December 2009, the clerk says someone in the clinic (could not recall staff's name) received a call from the Hospital Administrator's Assistant who allegedly advised staff that PI # 1 had been in the Administrator's office. PI # 1 was upset after being seen by the CRNP and he was also upset with the Administrative Assistant and the evaluation by the CRNP. The Assistant was advising the clinic that PI # 1 was upset. The clerk was asked if she had been advised that PI # 1 was not allowed in the clinic and she said, "They (Outpatient Clinic Director and the Administrator) were going to write a letter to the patient advising that he was no longer allowed in Clinic A." When the clerk was asked if she had been given instructions about action to take if PI # 1 presented to the clinic, she said, "No." The clerk's first encounter with PI # 1 was approximately one year ago when a physician (Physician # 2) came out of an examination room, after evaluating PI # 1 and asked the clerk to call administration. PI # came to the front window (clerk's desk) and also asked the clerk to call administration. When administration called the clinic, the clerk gave the telephone to the physician. PI # 1 became angry, loud and said he should have been given the telephone.

During PI # 1's appointment on December 29, 2009 the clerk reports she talked to the Outpatient Clinic Director about PI # 1 because of the call from Administration about PI #1 being upset after his last visit (prior to December 29th). According to the clerk, the director "took over" on December 29, 2009. The clerk did not see security in the clinic on December 29th and denies telling the CRNP or any other clinic staff that PI #l was not to be seen.

Medical Clerk # 2, interviewed on Janaury 13, 2010 at 3:30 PM said she had not been told "directly" that PI # 1 was not to be seen in the clinic, but she heard PI # 1 had given "providers difficulty." During the patient's appointment on December 29, 2009 another clerk (Clerk #1) reported "heresay" that PI # 1 was not to return to the facility because of his "temperament." Clerk # 1 called the Director and PI # 1 left without being seen.

Clerk # 2 says another physician (Physician # 2) "looked scared" and was "in a panic" after seeing PI # 1 (date unknown). The physician asked a clerk to call Administration. PI # 1 "stormed" out of the examination room and came to the clerk's window. The clerk reports P# 1 said, "I told ya'll to call Administration for me, not her (Physician # 2)."

Physician # 2, interviewed on Janaury 13, 2010 at 3:55 PM, reports she saw PI # 1 over one year ago. The physician spent an hour with PI # 1 trying to review PI # 1's multiple problems. PI # 1 requested narcotics. When the physician denied this request, PI # 1 began shouting and became verbally agressive and hostile. The MD asked PI # 1 not to talk loudly. The physician askded a clerk to call Administration when PI # 1 starting shouting at the clerk. PI # 1 agreed to talk with Adminsitrative staff.

During an interview with the Outpatient Clinic Director on January 13, 2010 at 4:05 PM, the director said the security officer "calmed" PI # 1 on December 29, 2009. Verbal direction about PI # 1 being banned from the clinic came from the Medical Director. According to the Clinic Director, the Medical Director said, "We need to send the patient a letter asking him not to come back. Looking back, all three clerks seemed afraid on 12/29/09."

During an interview at 10:10 AM on January14, 2010, the Chief Financial Officer (COO) was asked if an incident report about the mutiple incidents involving PI # 1 had been done and he said, "No." The COO reports PI # 1 has progressively gone through the physicians in the clinic and they now refuse to see the patient.

The Security Officer who responed to a call from Clinic A on December 29, 2009 about PI # 1 was interviewed on January 14, 2010 at 11:00 AM. The officer said he was told by a clerk from Clinic A that a patient "barred" from the hospital needed to be escorted off the premises. The patient said he received a letter from the clinic about this appointment. PI # 1 said he was not aware that he was barred from the clinic. The Clinic Director verified PI # 1's identify and informed the patient he had to leave. PI # 1 voluntarily left the clinic with the officer without incident. The officer said he wrote a report after the incident and would provide a copy to the surveyor.

The Incident Report, dated 1/14/2010 at 9:00 AM, documents the offense as: "Barred patient." Date of Incident: 12/29/09 (Time not documented). PI # 1's name was documented. Details: "On Dec. 29, 2009, (Outpatient Clinic Director's name) notified secuirty a patient that was barred was in Clinic A. The patient (patient's first and last name) was in the clinic for an appointment. Patient (last name) was escorted off the premises by Security. End of report."

During an interview with the Medical Director/Hospital CEO on January 14, 2010 at 1:25 PM, the Medical Director was asked if PI # 1 is "banned" from Clinic A. According to the Medical Ditector, PI # 1 is not banned from the clinic or hospital. The Director said, "Basically this is false because there is no documentation. The doctors in Clinic A will no longer see the patient." The patient was evaluated by the Pain Clinic Board Certified Pain Management Psychiatrist sometime in 2008. The patient wants Lortab...PI # 1 got angry and came to my office for medicine. The psychiatrist was not comfortable with PI # 1 returning to the pain clinic due to PI# 1's behavior during the evaluation. PI # 1 was referred back to Clinic A (Medicine Clinic).

According to the Medical Director, the hospital has considered not allowing PI #1 to continue as an outpatient. The Admnistrative Assistant heard this discussion and thought PI # 1 had been banned from the Outpatient Clinic. When the clinic staff called Administration on December 29th, the Assistant said PI # 1 was banned from the clinic.

PI # 1 called the Medical Director sometime after the appointment (does not recall date). The patient was very upset that he was told he was terminated without notice. The Medical Director informed PI # 1 she did not know what happened. The Director advised PI# 1 of the concern of the providers about his behavior. PI # 1 became hostile and said he had a right to come discuss the issue. The Medical Director verified no letter was sent to the patient and the documentation in the medical record is poor. The director wanted to meet with PI # 1, a representative of PI # 1's choice, the physicians, and the county attorney. The attorney reportedly advised staff should meet and develop expectations, send a copy of the plan to PI # 1 and then meet with the patient. PI # 1 was very loud and hostile on the telephone. The director advised PI # 1 of the attempt to schedule a meeting with all the involved parties. Because PI # 1 continued to be hostile, the director advised PI # 1 that she was terminating the conversation. The Medical Director said PI # 1 should not have been escorted off hospital property. "Everybody was reactionary." When asked about PI # 1's current status, the director said PI # 1 is still a patient.

The Medical Director said the hospital policy regarding patient termination requires a 30 day notice and provision of three provider options.

The facility failed to thoroughly document PI # 1's behavior in the medical record to reflect the rationale for considering terminating PI # 1 from the outpatient clinic. There is no documentation in the medical record on 12/29/09 about PI # 1's behavior or that security was called to the clinic. The facility informed PI # 1 that he was not allowed in the outpatient clinic and escorted the patient off the premises without written notification of termination from clinic services.