HospitalInspections.org

Based on interview and record review, the facility failed to follow and enforce policy to ensure compliance with the requirements of 489.24; specifically 489.24(a), providing an appropriate medical screening examination, for one patient (Patient #21) out of 33 cases reviewed. The facility sees an average of 410 emergency cases per month.
Findings included:

1. Review of Medical Staff Rules and Regulations effective 02/07/95, revised on 10/06/10 stated Psychiatric/medical screening and stabilizing treatment will be accomplished on all patients presenting themselves on the hospital premises (page 1, IA).

Review of hospital policy #PC-960, titled "Scope of Service; Assessment and Referral Center (ARC) Department", effective 08/10/09, without revision, stated:
-ARC staff members are required to adhere to EMTALA regulations and adhere to all hospital policies and procedures, including appropriate admission or transfer (page 1, #8);
-Two Rivers Behavioral Health System assesses individuals presenting to the Emergency Department. Emergency assessments include a medical screening evaluation from a Qualified Mental Health Professional (page 2, #9).


During an interview on 10/13/10 at 3:25 PM, RN E stated Patient #21 had not arrived at the hospital when he/she completed the intake assessment form on 9/30/10. RN E stated the information was provided by Case Manager J, with the Division of Family Services. Based on the information received, RN E felt Patient #21 was homicidal and met the criteria for a 96 hour hold (voluntary/involuntary commitment for 96 hours).

2. Review of an incident report dated 10/01/10, signed by Staff C, Director of the ARC, revealed Patient #21 had arrived on facility grounds on 09/30/10, with police, and was out of control.

During an interview on 10/12/10 at 11:00 AM, Staff C stated he/she was present when Patient #21 arrived at the hospital on 09/30/10, that Staff C went outside to the police van located in the hospital parking lot and instructed the officers to take Patient #21 to "detention". Police left with the patient.
During an interview on 10/13/10 at 3:25 PM, RN E, ARC nurse stated he/she saw Patient #21 arrive in shackles, in the back of a paddy wagon, in the hospital parking lot. RN E stated he/she did not assess Patient #21 before the Patient left with police.
During an interview on 10/14/10 at 3:20 PM, RN M, ARC nurse stated he/she informed Two Rivers staff, "We have to take the patient because the patient has already arrived." RN M stated he/she was later informed by staff the police had left with the patient after "someone" had gone outside and instructed the police to take the patient to detention.
During an interview on 10/14/10 at 4:00 PM, RN N, House Supervisor stated Patient #21 arrived at the facility with police, never came into the hospital, and was sent back with police.

The facility failed to follow policies for Patient #21 who presented to Two Rivers Psychiatric Hospital with law enforcement after making homicidal threats and being physically aggressive to the point he/she required police restraint. Patient #21 remained in a police van, in the parking lot of the hospital, and received no medical screening exam. Police were directed by hospital staff to take the patient to detention and the police left with the patient.

Based on interview and record review, the facility failed to provide a medical screening exam within the capability of the hospital's intake department for one (Patient #21) of 33 sampled patients. This resulted in the delay of the identification of a possible emergency medical condition. The facility sees an average of 410 emergency cases per month.
Findings included:
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D, from a teen shelter (Patient #21's residence) stated his/her supervisor contacted Two Rivers Psychiatric Hospital on 09/30/10 to ask if the hospital had the ability to admit Patient #21. According to Staff D, the supervisor was told Two Rivers could admit Patient #21, that the assigned bed would be held for Patient #21 until midnight, and that Patient #21 could come to the facility at any time.

Review of Patient #21's closed medical record dated 09/30/10 revealed RN E, a nurse in the Assessment and Referral Center (ARC), was contacted at 3:30 PM by Child Specialist I with the Division of Family Services (DFS), to arrange an inpatient admission (per inquiry call sheet).

During an interview on 10/18/10 at 10:25 AM, Child Specialist I, with DFS, stated at approximately 5:00 PM, Case Worker J arrived at Two Rivers to complete paperwork to admit Patient #21 to hospital.


Review of Patient #21's closed medical record dated 09/30/10 revealed RN E documented (without time entry) on page 10 of the intake assessment form that Patient #21:
-was a danger to others;
-that evaluation and treatment could not be done at a lesser level of care;
-had severe functional debilitation.
On page 11 of the form, RN E documented that Patient #21 would be:
-admitted as an inpatient to the adolescent unit;
-on elopement precautions;
-on assault precautions;
-observed for safety every 15 minutes.

During an interview on 10/13/10 at 3:25 PM, RN E stated Patient #21 had not arrived at the hospital when she completed the intake assessment form on 9/30/10. RN E stated the information was provided by Case Manager J, with the Division of Family Services. Based on the information received, RN E felt Patient #21 was homicidal and met the criteria for a 96 hour hold (voluntary/involuntary commitment for 96 hours).
During an interview on 10/29/10 at 2:24 PM, Case Worker J from DFS stated she was at Two Rivers hospital to complete admission paperwork for Patient #21's sometime between 4:00 PM and 6:00 PM, but left before the patient arrived. Case Worker J was informed by Two Rivers intake staff that he/she would not need to return when Patient #21 arrived because all of the necessary paperwork had been completed to admit the patient.

During an interview on 10/14/10 at 1:30 PM, Staff C, Director of the ARC stated Patient #21 was assigned an inpatient bed when the patient's intake information was received in the ARC.
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D stated he/she contacted the police department sometime after 4:00 PM on 09/30/10 to transport Patient #21 to Two Rivers. At approximately 5:15 PM, two officers arrived at the shelter to transport the patient, but the patient became so verbally assaultive and aggressive, that a third officer was called to assist with the transfer. At approximately 5:30 PM, police left with Patient #21, en-route to Two Rivers.
Review of a police document dated 10/20/10 showed at approximately 5:20 PM, a police patrol van transported Patient #21 from the shelter to Two Rivers Psychiatric Hospital.
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D stated immediately after Patient #21 left the shelter, Staff D contacted Two Rivers and spoke with (unknown) intake staff, informing them, "you have a bed on hold for this kid", that Patient #21 had escalated, required three officers to remove him/her from the shelter, was in shackles, and en-route to Two Rivers with police.
During an interview on 10/14/10 at 3:20 PM, RN M, ARC nurse stated she received a phone call that three officers were required to remove Patient #21 from the shelter after being placed in shackles.
During an interview on 10/13/10, at 3:25 PM, RN E stated the facility has the ability to accept aggressive patients on the adolescent unit.
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D stated RN M called and advised Staff D that, "It sounds as if he's too acute for our facility. I need to see what the doctor wants to do." Staff D asked RN M to contact Child Specialist I with DFS for any further information or concerns, as Patient #21 was "no longer a client here, we have discharged" him/her. Staff D provided RN M with Child Specialist I's contact information, but RN M refused to contact DFS. Staff D informed RN M the shelter "no longer has authority" since the patient had already left, but RN continued to refuse to speak with DFS regarding the patient.
During an interview on 10/14/10 at 3:20 PM, RN M stated she contacted Physician O (psychiatrist on-call) regarding Patient #21's aggression and "the doctor backed out of the admit." Staff M then contacted Patient's #21's shelter and informed them the hospital would not be able to accept the patient, but while RN M was on the phone with the shelter staff, Patient #21 arrived at the hospital with police. RN M stated he/she informed Two Rivers staff it was "too late, we have to take the patient." RN M called Physician O to inform him/her Patient #21 had arrived and Physician O gave medication orders to sedate the patient if needed. RN M then contacted RN N, House Supervisor, who picked up the ordered sedation medications and the facility prepared for a "code white" (takedown or de-escalation of a patient). RN M stated hospital staff began coming from the inpatient units to prepare to get Patient #21 to the inpatient floor without problems.
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D stated a voicemail was received at 6:14 PM from RN M to return call Two Rivers soon as possible. When Shelter Staff D contacted the facility, RN M asked what Patient #21's allergies were.
Review of an e-mail dated 10/20/10 at 5:05 PM, Risk Manager B wrote Physician O provided a telephone order to RN M on 09/30/10, (time unknown) for Benadryl and Haldol (medications used for sedation).
During an interview on 10/14/10 at 4:00 PM, RN N, House Supervisor stated he picked up sedation medications as ordered by Physician O, and went outside when the patient arrived.
Review of an incident report dated 10/01/10, signed by Staff C, Director of the ARC, revealed Patient #21 had arrived on facility grounds on 09/30/10, with police, and was out of control.
During an interview on 10/13/10 at 3:25 PM, RN E, ARC nurse, saw Patient #21 in shackles, in the back of a paddy wagon in the hospital parking lot, but was not acting out.
During an interview on 10/12/10 at 11:00 AM, Staff C stated when Patient #21 arrived at the facility, Staff C went outside to the police van, located in the hospital parking lot, and instructed the officers to take Patient #21 to "detention", and the police left with the patient.
During an interview on 10/14/10 at 4:00 PM, RN N, House Supervisor, stated Patient #21 never came into the hospital and left with police.
During an interview on 10/29/10 at 10:40 AM, Shelter Staff D stated at approximately 6:30 PM, shelter staff informed him/her that police had called and were bringing Patient #21 back to the shelter. At approximately 6:45 PM, Shelter Staff D contacted Child Specialist I that Patient #21 had been returned to the Shelter after the facility would not accept him/her.
During an interview on 10/18/10 at 10:25 AM, Child Specialist I, with DFS stated he/she received a phone call from Patient #21's shelter, indicating Two Rivers had turned the patient away.

During an interview on 10/29/10 at 3:45 PM, Child Specialist I stated Patient #21 was taken the following day to a second psychiatric hospital, evaluated, and received psychiatric care.