HospitalInspections.org

Based on hospital policy review, Medical staff rules and regulations, medical record review, staff and physician interviews, the hospital failed to comply with §489.24 as evidenced by: developing and enforcing a Dedicated Emergency Department (DED) "Saturation" policy that resulted in failure to accept behavioral health patients while other medical patients were accepted; failing to ensure a medical screening examination upon arrival for a patient with a mental health emergent medical condition; and failing to provide within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize a patient with a mental health emergent medical condition.

The findings include:

A. Review of the "Emergency Department Behavioral Health Saturation" policy effective 11/03/2014 revealed "PURPOSE: To establish guidelines for criteria on when the Emergency Department may declare saturation due to the influx of behavioral health patients. POLICY: The (hospital name) Emergency department may declare saturation in accordance with local Law Enforcement Services when: Two ED beds are filled with high-acuity, (e.g., suicidal ideation, homicidal behavior, aggressive behavior), behavioral health patients leaving only two beds available for critical patients. Law enforcement officials are NOT available to maintain a constant presence on site, at the bedside. Sitters from the list of approved personnel are NOT available to maintain a constant presence on site, at the bedside. PROCEDURE: 1. The Emergency Department Charge Nurse and the Emergency Department Provider make the tentative decision based on the above criteria for the Emergency Department Behavioral Health saturation. 2. The Charge Nurse notifies the ED Nursing Manager of the tentative decision for temporary saturation. If the ED Nursing Manager is unavailable, the Charge Nurse will notify the Administrator-On-Call for final approval. 3. All local agencies are notified via telephone. (town and county law enforcement). 4. The Charge Nurse will maintain a saturation log of the person and time notified. The saturation log may consist of information being documented on a progress note. 5. The Charge Nurse and the Emergency Department Provider will determine when saturation is to be lifted in accordance with the above criteria. All appropriate agencies will be notified of the termination of the saturation time, date and person(s) notified. This information will be documented in the saturation log. The Charge Nurse will notify the ED Nursing Manager and/or Administrator on call when the termination of the ED saturation is lifted. 6. The Charge Nurse will refer to staffing policies and or disaster policies as needed for direction.

Interview on 12/09/2014 at 1130 with the CEO and CNO revealed a new policy was put in place on 11/03/2014 related to emergency department behavioral health saturation. Interview revealed the new policy was going to be presented to the Medical Staff on 12/09/2014 (day of the interview). The administrative staff stated that there had been two times in the past month when they had implemented the behavioral health saturation policy. Interview revealed the ED did not go on "medical diversion" but diverted IVC (involuntary commitment) patients for "safety reasons." The CEO stated "We have limited resources and behavioral health patients create a burden on us. We have two rooms that we use for behavioral health patients. We strip the rooms for safety." Interview revealed there was no hospital security presence in the hospital. The CEO stated staff coordinate with law enforcement to stay with a patient if the patient exhibits threatening or violent behavior. The CEO stated the ED has not refused to take these patients if they presented here. He stated "If they show up here, we will provide care. It overwhelms our capabilities. We were trying to send them to a location with better resources (behavioral health services)."

Interview on 12/09/2014 at 1415 with the CEO and CNO revealed there was a behavioral health saturation that started on 10/30/2014 at 1700 and ended on 10/31/2014 at 0340 (10 hours and 40 minutes duration). Interview revealed PA #4 had called the CEO and said that they were overwhelmed and they had 2 IVC patients and the magistrate called and said there was a potential third IVC patient that would be coming. Interview revealed PA #4 reported that the ED was struggling with resources topped out. PA #4 reported that the ED was saturated with patients, both behavioral and medical and he felt overwhelmed and did not feel he could handle another behavioral health patient. He did not feel like there was adequate staff available to manage. Interview revealed there was a physician on call that was not contacted. The CEO stated he did not feel that would have helped the situation. The CEO stated he told PA #4 to go on diversion and reported that EMS (emergency management services) and 911 were notified of the saturation. Interview revealed there was a second incident of behavioral health saturation on 11/20/2014 at 1513 when PA #3 called the CNO saying that they already had two IVC patients in the ED and the magistrate had called saying there would be two more IVC patient coming into the ED. Interview with the CNO revealed PA #3 called the magistrate to notify the ED could not take any more IVC patients. Interview revealed PA #3 found out they were not bringing the IVC patients and canceled the saturation. Interview revealed the local magistrates and law enforcement officers would call the ED prior to bringing an IVC patient into the ED. Interview revealed the ED did not divert all patients during the time they were on "behavioral health saturation" and only diverted the behavioral health patients. Interview revealed the new policy for behavioral health saturation has only been communicated to the ED staff and has not yet been communicated to local law enforcement.

Telephone interview on 12/12/2014 at 1415 with PA #4 revealed there were only 4 beds in the ED and having IVC patients" limits the regular" emergency department patients. The PA stated he did go on behavioral health saturation in October due to increased capacity and acuity. The PA stated "We were saturated with medical and psychiatric patients. We had 2 or 3 IVCs here taking up ED space. There were 3 or 4 waiting. I called (CEO) and told him we were saturated." Interview revealed the saturation policy was implemented during that time. Interview revealed the saturation policy only restricted IVC patients from coming to the ED and it did not restrict all patients from coming to the ED.

Interview on 12/10/2014 at 1630 with PA #3 revealed there was a time in October 2014 when the ED had 4 IVC patients at one time and there are only 5 rooms available. The PA stated "We were not able to function as an ED at that time." Interview revealed administration was aware and the behavioral health saturation policy was developed as a result. Interview revealed sometime in November (unsure of the date) PA #3 had called the CNO because the ED already had 2 IVC patients and the magistrate called to say there was a third that would be coming. Interview revealed the PA was told to implement the behavioral health saturation policy after consultation with the CNO. Interview revealed nursing staff called the magistrate and sheriff department to notify them that any further IVC patient would need to be diverted to another location.

Interview on 11/12/2014 at 1100 with Physician B (DED Medical Director) revealed there had been changes made to the saturation policy around a month ago that the ED would only take two IVC patients. Interview revealed the concern is that there are only four DED rooms and they were trying to keep rooms open for non-behavioral health DED patients. Interview revealed Physician B was not part of the original decision to change this policy. Interview revealed the physician was informed of the change in the saturation policy by nursing staff while working in the ED.

Review of the DED log revealed on 10/30/2014 from 1700 through 10/31/2014 at 0340 eight non-behavioral health patients were evaluated and treated during the time the DED was on behavioral health saturation.

B. The hospital failed to provide a medical screening examination upon arrival for a patient that presented with an emergency medical condition in 1 of 23 sampled patients presenting to the hospital's DED (Dedicated Emergency Department) (Patient #6).

~ cross refer to 489.24(r) and 489.24(c) Medical Screening Examination, Tag A2406.

C. The hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize 1 of 23 patients with a mental health emergent medical condition (Patient #9).

~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

Based on hospital policy review, medical staff rules and regulations, medical record review and physician interview, the hospital failed to provide a medical screening examination upon arrival for a patient that presented with an emergency medical condition in 1 of 23 sampled patients presenting to the hospital's DED (Dedicated Emergency Department) (Patient #6).

The findings include:

Review of the hospital's "EMTALA - Medical Screening Exam and Stabilization Policy" approved 02/11/2014 revealed "... When an individual comes to the (name of hospital) Emergency Department (ED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospital (including ancillary services) shall be performed by a physician or qualified medical personnel (QMP) in order to determine whether an EMC exists. ...The hospital is obligated to perform the MSE in order to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to a MSE. ... The physician or QMP on duty is responsible for the general care of all individuals presenting to the ED; and the responsibility remains with the physician or QMP until the individual is admitted, transferred, or discharged. ..."

Review of medical staff rules and regulations reviewed and revised November 2004 revealed qualified medical personnel (QMP) were defined as "members of the medical staff or their designees. Designees are Physician Assistants or Family Nurse Practioners."

Review of Patient #6 revealed a 31 year-old male that presented to the DED on 11/15/2014 at 0053. Review of triage nursing notes at 0053 recorded the patient's chief complaint as "I don't know. See (mobile crisis) assessment - voluntary commitment. Denies visual and auditory hallucinations. Complains of stomach ache and diarrhea all day. Needs medical clearance and placement per note attached with (mobile crisis) assessment. States he is missing his brother. 'Had a heart attack and died' a long time ago. Posture is relaxed and slumped. Voice monotone. Speech difficult to understand. States I want to go back to (assisted living facility) tonight." Review of triage vital signs revealed blood pressure (BP) 132/88, pulse (P) 105, respirations (R) 16, temperature (T) 98 and oxygen saturation 98%.
Review of a mobile crisis assessment (staff contracted to conduct behavioral screening evaluations) completed on 11/14/2014 at 2330 by MSW #1 revealed the patient stated he tried to hang himself and he was hearing voices telling him to kill somebody. Review revealed the patient was found in the hallway with a shoe string tied around his neck and another around a door knob. Review revealed the patient reported that he wanted to kill himself and maybe harm others. Review of the assessment revealed a note attached that stated the patient is voluntary and is in need of medical clearance and placement. Review of nursing notes at 0110 revealed the patient refused to go into a room and stated he wanted to go home. Nursing notes at 0116 revealed the nurse contacted the assisted living facility (ALF) where the patient resided as requested by the provider. Review of nursing notes at 0130 revealed the ALF staff was told that the patient wanted to return to the facility. Notes revealed that the ALF staff advised to take IVC (involuntary commitment) if necessary, as directed by the provider. Review of the notes revealed the patient left at 0130 ambulatory in no apparent distress to return to the ALF.

Review of Patient #6's DED record revealed he returned to the DED via police officer on 11/15/2014 at 2200 (21 hours after prior departure). Review of triage notes at 2200 revealed the patient "admitted to placing a mini-blind cord around his neck." Review of the triage notes revealed the patient denied suicidal or homicidal ideations and was just "upset and mad" because he was missing his brother. Notes recorded the patient was calm and cooperative with staff at triage. Vital signs were recorded as BP 130/88, P 91, R 18, T 97.8 and oxygen saturation 98%. Review of nursing notes revealed the patient's personal belongings were removed and the patient was placed in a gown at 2220. Nursing notes at 2315 recorded that mobile crisis staff brought a copy of an assessment done prior to the patient's arrival to the DED. Review of the mobile crisis assessment evaluation revealed it was completed on 11/15/2014 at 2034 by BSW #2. Review of the assessment revealed "... Client was evaluated by (mobile crisis) on 11/14/2014 after he took his shoelaces and tied one end to the door knob and wrapped the other end around his neck in an attempt to kill himself. At that time he stated that he was hearing voices telling him to kill somebody. (mobile crisis) recommended inpatient psych hospitalization. Client was brought to (Hospital A) and was later released from there because he states he didn't want to stay there so they let him come back here. (ALF) staff report that earlier this evening client told other residents that he was going to hang himself. Residents reported that to staff and when staff went into his room, he had the cord of the window blind wrapped around his neck. He told staff that he was going to kill himself because he doesn't want to live anymore. ..." Review of the mobile crisis summary revealed a recommendation that the client be placed under involuntary commitment (IVC) and be admitted for inpatient psychiatric treatment. Review revealed a medical screening examination was conducted on 11/16/2014 at 0735 by Physician A (9 hours and 35 minutes after the patient arrived in the DED). Review of the physician's notes recorded the patient was "found yesterday with a cord from his shoelace around his neck. He denies that he wants to kill himself. Says just sad that his brother died of a heart attack. Multiple visits to ER with same complaints. ..." Review of the notes revealed the patient had a history of anxiety, depression, impulse control and mental retardation. Review revealed the physician documented "suicidal ideation - voiced - Y (yes checked)." Further notes documented "Denies wanting to kill himself - just sad." Review of the notes revealed the patient was having no hallucinations or delusions. Record review revealed a urine drug screen, CBC and chemistry were completed. Review revealed diagnoses were recorded as "chronic depression, anxiety disorder and impulse control disorder." Review revealed a disposition of "outpatient commitment" papers signed. Review of the involuntary commitment (IVC) paperwork signed by Physician A on 11/16/2014 at 1950 revealed "Recommendation for Disposition" was listed as "outpatient commitment." Review of the record revealed the patient was discharged home on 11/16/2014 at 0815.

Interview was attempted with Physician A on 12/12/2014. The physician was not available for interview.

Interview on 12/12/2014 at 1100 with Physician B revealed he was the DED Medical Director. Physician B stated that the physicians or mid level providers (Physician Assistants or Nurse Practioners) should see patients as soon as possible after they arrive in the DED. Interview revealed there is not a documented time frame but that a medical screening exam should be conducted shortly after the patient arrives. Physician B reviewed the DED record for Patient #6 and stated there was a delay in conducting a medical screening examination. Interview confirmed the MSE was not conducted until 9 hours and 35 minutes after the patient arrived. Physician B was unable to explain the reason for the delay and stated there was a problem with the timeliness of the MSE for this patient.

Based on hospital policy and procedure review, closed medical record review, and staff and physician interviews, the hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize 1 of 23 patients with a mental health emergent medical condition (Patient #9).

The findings include:

Review of the EMTALA - Transfer Policy dated 04/14/2012 revealed "... If an individual (or the individual's designated representative) comes to the (name of hospital) emergency department (ED) requesting (or a prudent layperson observer would assume the individual would be requesting) medical care and an EMC (emergency medical condition) is identified, the hospital must provide and appropriate medical screening examination (MSE) and either: further medical examination and treatment, including hospitalization if necessary, as required to stabilize the medical condition within the capabilities of its staff and facilities; or a transfer to another more appropriate or specialized facility after provision of treatment necessary to minimize the risks to the health of the individual or in the case of a pregnant woman, to the unborn child. ..."

Closed medical record review of Patient #9 revealed a 52 year-old male that arrived in the dedicated emergency department (DED) via police on 09/20/2013 at 1350 for involuntary commitment (IVC). Review of the triage notes at 1351 recorded mobile crisis (contract staff that provide behavioral assessments) was en route for evaluation. Review revealed the patient was "excited" and stated that he "had lost his woman." Vital signs were recorded as blood pressure (BP) 110/74, pulse (P) 100, respirations (R) 18 and temperature (T) 97.6 Fahrenheit. Review of the triage notes recorded the patient "Pt (patient) denies SI (suicidal ideations. States he wants to hurt the man raping his girlfriend. Denies visual/auditory hallucinations. Pt is delusional. ..." Review of the notes revealed the patient was homeless.
Nursing notes at 1455 recorded that mobile crisis staff was in the DED to evaluate the patient. Review of the mobile crisis assessment conducted at 1431 revealed the patient thinks that a local pawn shop owner is raping his girlfriend. The patient told the police officer that he would hurt the man for keeping his girlfriend from him. Review revealed the officer secured IVC paperwork because the patient was a danger to himself and others. Review of the notes revealed "Per (PA #3) client has been to this ED 5 times in a 48 hour period and to his personal doctor who is (xxx) 13 times just yesterday alone. ... " Review of the assessment notes revealed a recommendation to place the patient under IVC for delusional thoughts and behaviors. Review of physician's notes revealed the patient had a medical screening examination at 1530 by PA #3. Review of the physician's notes revealed the patient had a history of schizophrenia with recent IVC 3 - 4 weeks ago. Notes revealed the patient was living at a local motel and was having "multiple delusional ideations." Review revealed a clinical impression of "acute schizophrenia" and "delusional" and recorded the patient was cleared medically for psychiatric referral. Review revealed Physician C signed IVC paperwork on 09/20/2013 at 1530 and recorded that the patient was "hallucinating, delusional, homeless and unable to care for himself or safely survive. Thinks he is 'ZZ Top' and he's been 'stalking' a woman in the community." Review of nursing notes on 09/20/2013 recorded the patient was out of his room, wanting to leave, frequently required redirection and removed his gown and walking around the DED in his underwear. Review revealed medications for behavior were administered as needed at 2035 (Haldol), 2040 (Vistaril), 2222 (Haldol) and 2330 (Haldol and Ativan). Review of PA progress notes on 09/20/2013 recorded the patient was agitated, pacing the hall and having flight of ideas. Review of nursing notes from 09/21/2013 recorded the patient was walking and dancing in the hall in his underwear and delusional. Review revealed a sitter was placed with the patient on 09/21/2013 at 1415. Review revealed the patient received medications for behaviors on 09/21/2013 at 0900 (Haldol), 0955 (Haldol), 1225 (Haldol) and 1805 (Haldol and Ativan). Review of PA progress notes on 09/21/2013 at 1805 revealed the PA was called by the sitter to talk with the patient due to increasing agitation, taking off his clothes and threatening to throw a chair through the window. Review of the note revealed "Patient assessed. He is calm, but agitated. He refers to people not present, to discussions with Jesus, to asking when 'that guy' is coming to get him and take him home. ..." Review revealed the patient refused oral medication and injectable medication was administered. Review of nursing notes dated 09/22/2013 revealed the patient continued to require continuous redirection. Review of a note at 0815 recorded that the patient would "not stay in his room for over 1 - 2 minutes at a time. Patient has dentures in hand. States that he was going to break them ~ approx. 1 minute later, he breaks them. ..." Nursing notes at 0840 recorded that a nursing assistant (CNA) had taken the patient's vital signs and was leaving the room when the patient "balls up his fist and hits (CNA) on right arm when he was exiting the patient's room." Nursing notes revealed a sitter was at the bedside at 0915 and 1705. Review of the medication administration sheet (MAR) revealed the patient received medications as needed for behavior on 09/22/2013 at 0005 (Ativan) and 0840 (Haldol and Ativan). Review of PA progress notes dated 09/22/2013 at 0905 recorded that the patient was observed attempting to assault another male patient. Review of nursing notes on 09/23/2013 recorded the patient was in and out of his room requiring frequent redirection. Notes recorded that the patient wanted to leave. Review of nursing notes from 09/24/2013 at 0140 revealed the patient "continued to open and close the door to hear door chimes..." Nursing notes dated 09/24/2013 recorded the patient was agitated, wandering and wanting to leave, remained delusional and talking about girlfriend. Notes at 0415 documented "Called to room - want to go home - If not I'm going to flood this place - Had water running in room..." Review of the MAR revealed the patient received as needed medication for behaviors on 09/24/2013 at 1515 (Haldol and Ativan) and 2240 (Haldol). Review of nursing notes dated 09/25/2013 at 0736 recorded the patient was delusional, but cooperative and was out of his room every 5 minutes, wanting to leave and call his girlfriend. Review revealed the patient had increased anxiety at 1945. Notes at 2255 recorded that a cardiac resuscitation was occurring in the DED and the patient had to be returned to his room multiple times. Notes at 2310 recorded the patient was still agitated and and a police officer was at the bedside. Review of the MAR revealed as needed behavioral medications were administered on 09/25/2013 at 1130 (Haldol and Ativan), 1625 (Geodon), 2000 (Geodon), 2255 (Haldol), 2310 (Ativan) and 2335 (Haldol 20 milligrams intramuscular). Review of Physician A's progress notes dated 09/25/2013 at 2230 revealed "Patient wanders in and out of exam room and into emergency room - Having to give increasing dose of Ativan and Haldol IM (intramuscular). Review of Physician's orders revealed an order on 09/26/2013 at 0030 from Physician A for bilateral wrist restraints for combative behavior, threatening and physically attempting to harm others or property. Review of nursing notes at 0030 recorded "Restraints placed on patient with doctor orders. Placed with two fingers space. 09/26/2013 0035 Patient out of restraints. Attempted to place patient back in restraint. Patient punched (nurse) with a closed fist to right side of face. Nurse out of room. 09/26/2013 0040 Officer at bedside with patient." Review of the MAR revealed the patient received Haldol 20 milligrams and Ativan 2 milligrams intramuscular on 09/26/2013 at 0050. Review of the notes revealed the patient was sleeping at 0200, 0345 and 0515. Nursing notes at 0715 recorded new physician ordered were received. Review revealed Physician A gave a verbal order on 09/26/2013 at 0710 for "IVC dropped. Patient D/C (discharged)." Review of Physician A's progress notes dated 090/26/2013 at 0700 revealed "Slept 4 hours with restraints on - calmer this AM. Will release from commitment." Review of IVC paperwork dated 09/26/2013 at 0710 signed by Physician A recorded the patient "wanders around the emergency room. Denies self-destruction or homicidal thoughts." Review revealed the recommendation was to "Release Respondent and Terminate Proceedings." Review of nursing notes dated 06/26/2013 at 0752 recorded that the patient was discharged home via police after medications and discharge instructions were reviewed with the patient.

Interview on 12/11/2014 at 1610 with Physician A revealed she remembered Patient #9. The physician stated the patient kept coming out of his room. Physician A stated they were doing CPR (cardiopulmonary resuscitation) on another patient and she asked a nurse to see what Patient #9 needed. The physician stated Patient #9 hit the nurse in the face. The physician stated the patient was restrained after that and given medication for behavior. The physician stated her decision to discharge the patient the next morning was made "after she conferred with the nurses. He accepted counseling about leaving the room to go to the bathroom and slept voluntarily. After multiple doses of Haldol, he was calmer. He was not delusional at the time of discharge. He was not hallucinating. He responded well to medical staff. I would not release him if he was out of control. I did not feel he was a threat to self or others. I should have documented better."

Interview on 12/12/2014 at 1100 with Physician B revealed he was the DED Medical Director. Physician B reviewed Patient #9's DED record and stated he would have reevaluated the patient before discharging him. The physician stated the patient had a 6 day history and he would have wanted to see the patient have "more time of calmness, for a longer period of time" before discharge. Physician B stated the patient demonstrated psychosis and stated "This is a major deviation from the standard of care. We can discharge homeless patients if they are medically cleared and have the capacity to make decisions. I can't tell if he was ready for discharge."

NC00102520 and NC00102308