HospitalInspections.org

Based on review of hospital A's (Dale Medical Center) policies and procedures, Medical Records (MR), transfer request log, New Day Behavioral Health (hospital A's psychiatric unit) Adult Unit Bed Census, New Day Behavioral Health Master Staffing Grid, on-call physician calendar, Hospital B (Referring Hospital number one) Emergency Department (ED) MR, Hospital C (Referring Hospital number two) ED MR, Transfer Center Call Summary, and staff interviews, it was determined the hospital failed to:

1. Place a patient who presented to the Emergency Department (ED) with symptoms of psychiatric disturbances on an involuntary hold for the completion of the Medical Screening Exam (MSE) and mental health screening exam.

2. Reassess a patient for the mental competency to make the decision to leave the facility Against Medical Advice (AMA) by a physician prior to the patient's discharge from the ED.

3. Provide an appropriate MSE, mental health screening exam, that was within the capability of the hospital's emergency department including ancillary services (on-call psychiatrist) routinely available to the emergency department whether or not an emergency medical exited, and failed deter and/or prevent a patient from leaving the ED prior to the completion of the MSE who was experiencing auditory hallucinations, unclear thinking, and confusion.

4. Accept from Hospital B and Hospital C, a referring hospital within the boundaries of the United States, an appropriate transfer of an individual who required such specialized capabilities or facilities when Hospital A had the capability and capacity to treat the patient who had an emergency psychiatric condition.

This deficient practice affected one of one psychiatric MRs reviewed who left AMA, including Patient Identifier (PI) # 2, and one of one psychiatric MRs reviewed who Left Without Being Seen, including PI # 16, two of two denied transfer requests reviewed, including PI # 23 and PI # 24, and had the potential to affect all patients served by the hospital ED with a psychiatric problem or requiring transfer to the hospital.

Findings Include:

Refer to Tags- A 2406, and A 2411 for findings.

Based on review of the hospital policies and procedures, Medical Records (MR), Hospital Psychiatric On-call physician calendar, and interviews with staff it was determined the hospital failed to:

1. Place a patient who presented to the Emergency Department (ED) with symptoms of psychiatric disturbances on an involuntary hold for the completion of the Medical Screening Exam (MSE) and mental health screening exam.

2. Reassess a patient for the mental competency to make the decision to leave the facility Against Medical Advice (AMA) by a physician prior to the patient's discharge from the ED.

3. Provide an appropriate MSE, mental health screening exam, that was within the capability of the hospital's emergency department including ancillary services (on-call psychiatrist) routinely available to the emergency department whether or not an emergency medical exited, and failed deter and/or prevent a patient from leaving the ED prior to the completion of the MSE who was experiencing auditory hallucinations, unclear thinking, and confusion.

This deficient practice affected one of one psychiatric MRs reviewed who left AMA, including Patient Identifier (PI) # 2, and one of one psychiatric MRs reviewed who LWBS (left without being seen), including PI # 16, and had the potential to affect all patients served by the hospital ED with a psychiatric problem.

Findings include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy
Policy Number: 16429730
Revised Date: 8/24

1. EMTALA Compliance Policy.

...1.2. General Policy Statement... It is the policy of this hospital that all persons presenting for unscheduled procedures or evaluation...shall receive a MSE within the capabilities of the ED and the ancillary services routinely available to the emergency services of the hospital, including examination...and the services of appropriate on-call physicians where indicated...

Procedure:

1.5 Capabilities: Capabilities encompass... privileged medical staff and technical staff of this hospital as it pertains to the nature, scope, and degree of services that can be provided by this hospital...

2. Areas of Practice: ...Psychiatry...

9. Psychiatric Assessment:

A. Patients presenting with symptoms of psychiatric disturbances are considered to have an Emergency Medical Condition (EMC) under federal law. They shall receive a MSE and mental health assessment...

B. The patient may be involuntarily held until a complete MSE and mental health screening exam are completed and a determination is made by the ED physician or authorized physician that the patient's condition has stabilized or improved and no longer represents an EMC...

D. Indications for mental health screening include, but are not limited to, primary complaints or secondary observations of:

...g. Flat affect.
h. Manic status.
i. Altered mental state.
j. Documented inability to maintain nutrition or safety.

Hospital Policy: Prescreen of Psychiatric Patients in the ED
Policy Number: 16834018
Revised Date: 10/24

...Procedure:

For patients...are a danger to themselves or others, or lack capacity to give informed consent, Emergency Detention/commitment procedures may be instituted.

1. PI # 2 presented to the hospital ED on 5/14/24 at 4:44 AM via ambulance with a chief complaint of psychiatric problem.

Review of the Triage Assessment dated 5/14/24 at 4:45 AM revealed the patient was experiencing auditory hallucinations which were saying they were going to harm the patient, was unable to sleep due to the hallucinations, the patient had a history of anxiety, depression, and Schizophrenia.

Review of the ED Physician Note dated 5/14/24 at 4:53 AM revealed the patient was experiencing auditory hallucinations, was unable to care for self, was unable to control self, had unclear delusional thinking, and bizarre behavior. The ED Physician documented an impression of Manic Episode, Severe with Psychotic Symptoms.

Review of the ED nursing note dated 5/14/24 at 6:24 AM revealed the hospital psychiatric unit (New Day Behavioral Health) was notified of the need for an evaluation on the patient.

Review of the ED nursing note dated 5/14/24 at 6:46 AM revealed the patient requested to leave the hospital ED AMA. The ED physician was notified and stated the patient was not on a psychiatric hold but is advised to stay for the psychiatric evaluation (mental health screening exam). The nurse documented speaking with the patient who agreed to wait a little longer for the psychiatric evaluation.

Review of the ED disposition note dated 5/14/24 at 7:01 AM revealed the patient left the ED AMA.

Review of the MR revealed no documentation of a mental health screening exam and and no documentation the ED physician reexamined/reevaluated
the patient's competency to make the decision to leave AMA.

Review of the hospital Psychiatric On-call physician calendar dated 5/14/24 revealed the hospital did have a Psychiatrist on call. The hospital had the capability to provide a psychiatric evaluation for Patient #2 on 5/14/2024.

An interview was conducted on 11/6/24 at 10:47 AM with Employee Identifier (EI) # 1, Director of Quality/Risk Management who confirmed there was no documentation of a mental health screening exam, no documentation the patient was placed on an involuntary hold for the completion of the MSE and mental health screening exam, and no documentation the ED Physician reexamined/reevaluated the patient's competency to make the decision to leave the hospital AMA prior to the patient leaving the hospital ED AMA. EI # 1 confirmed the hospital did have a Psychiatrist on call on 5/14/24.

An interview was conducted on 11/6/24 at 2:43 PM with EI # 9, Interim Medical Director of Hospital A. EI # 9 verbalized if a patient presented to the ED and was a danger to self, danger to others, or they had severe psychosis, the physician would contact the psychiatrist. If a psychiatrist was not available, then two physicians would review, and the patient would be placed on a 72-hour hold.

2. PI # 16 presented to the hospital ED on 10/8/24 at 8:34 PM with a chief complaint of psychiatric problem.

Review of the ED Triage Assessment dated 10/8/24 at 8:48 PM, by EI # 3, ED Registered Nurse (RN), revealed the patient was experiencing auditory hallucinations, unclear thinking, and confusion. The patient's family stated the patient was wandering around the neighborhood. The patient claimed someone had called him/her to come down the street.

Review of the ED nursing assessment dated 10/8/24 at 9:02 PM, by EI # 3, revealed the patient had a flat affect, was experiencing weakness, slurred speech, and had a history of Bipolar Disorder in addition to the Triage Assessment findings.

Review of the ED disposition note dated 10/9/24 at 12:37 AM revealed the patient left the ED without being seen (LWBS).

Review of the MR revealed no documentation of a MSE, mental health screening exam, or the patient was deterred and/or prevented from leaving the ED prior to the completion of the MSE.

Review of the hospital Psychiatric On-call physician calendar dated 10/8/24 revealed the hospital did have a Psychiatrist on call. The hospital the capability to provide a Psychiatric examination for patient #16 on 10/8/24.

Review of EI # 3's personnel file on 11/6/24 revealed EI # 3's date of hire as 3/24/22. Further review of EI # 3's personnel file revealed no documentation EI # 3 had been provided education on EMTALA.

An interview conducted on 11/6/24 at 10:57 AM with EI # 1 and EI # 2, Chief Nursing Officer, who confirmed there was no documentation of a MSE, mental health screening exam, or the patient was deterred and/or prevented from leaving the ED prior to the completion of the MSE.

An interview conducted on 11/6/24 at 1:56 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 3 had been provided education on EMTALA.

An interview conducted on 11/6/24 at 2:43 PM with EI # 9, who verbalized when a patient comes into the ED with a psychiatric problem the patient would need to be evaluated for suicidal ideation, homicidal ideation, delusions, and psychosis to see if the patient is a danger to self or others. EI # 9 verbalized if the patient was a danger to self or others or they had severe psychosis, the physician would contact the psychiatrist. If a psychiatrist was not available, then two physicians would review, and the patient would be placed on a 72-hour hold.

The facility failed to ensure that their own policy and procedure was fallowed as evidenced by failing to place Patient #2 and Patient #16 on voluntary hold until the medical screening examinations and mental health examinations were completed as stated in the facility's policy.

Based on review of hospital A's (Dale Medical Center) policies and procedure, medical records (MR), transfer request log, New Day Behavioral Health (hospital A's psychiatric unit) Adult Unit Bed Census, New Day Behavioral Health Master Staffing Grid, on-call physician calendar, Hospital B (Referring Hospital number one) Emergency Department (ED) MR, Hospital C (Referring Hospital number two) ED MR, Transfer Center Call Summary, and staff interviews, it was determined Hospital A refused to accept from Hospital B and Hospital C, a referring hospital within the boundaries of the United States, an appropriate transfer of a patients who required such specialized capabilities or facilities when Hospital A had the capability and capacity to treat the patients who had an emergency psychiatric condition.

This did affect Patient Identifier (PI) # 23 and PI # 24, two of two denied transfer requests reviewed, and had the potential to affect all patients requiring transfer to the hospital.

Findings Include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy
Policy Number: 16429730
Revised Date: 8/24

1. EMTALA Compliance Policy.

Procedure:

1.5 Capabilities: Capabilities encompass... privileged medical staff and technical staff of this hospital as it pertains to the nature, scope, and degree of services that can be provided by this hospital...

2. Areas of Practice: ...Psychiatry...

3. Capacity: ...physical ability of the facility to accommodate the patient, including bed availability, staff ability, or availability... A hospital has the capacity to accommodate a patient if it has previously accommodated more patients using reassignment of beds, early discharge, staff call-backs, and use of other areas of the facility...

Hospital Policy: Pre-Admission Psychiatric Assessment for the Behavioral Health Units
Policy Number: 16524097
Revised Date: 10/24

Purpose: The pre-admission assessment is designed to gather critical information from prospective patient to assess their eligibility for acute in-patient psychiatric services.

Criteria for Admission

...The patient is 19 years or older...

The patient must meet one or more of the following criteria:

...Has been physically assaultive to a degree...that threatens the life or safety of other persons.
...Acute deterioration of the patient's behavior, coping skills, or ability to care for self to a degree that creates a risk of harm to self or others...

Medical/Condition Admission Exclusionary Criteria

...Severe or profoundly developmentally delayed individuals (IQ (intelligence Quotient- test or subset designed to assess human intelligence) of < (less than) 70) with no acute behavioral change or no known psychiatric disorder or no expectation for a positive response to treatment.

Behavioral or baseline cognitive impairment to such a degree that they would be unable to benefit from the treatment interventions offered...or the patient is unable to function at a minimally acceptable level within the acute inpatient treatment program.

Hospital A, Dale Medical Center, documentation:

1. Review of the hospital transfer request log revealed a request for transfer was received from Hospital B (transferring hospital) on 10/11/24 (no time documented) for PI # 23. Further review revealed PI # 23 was denied due to not meeting criteria with a comment of "mental retardation and anger."

Review of New Day Behavioral Health (hospital A's psychiatric unit) Adult Unit Bed Census from 10/10/24 at 12:00 AM to 10/11/24 at 5:00 PM, revealed the 13-bed unit had two beds available. Further review revealed the unit was staffed with two nurses and two mental health technicians on 10/10/24 from 12:00 AM to 10/11/24 at 7:00 AM and two nurses and three mental health technicians on 10/11/24 from 7:00 AM to 5:00 PM.

Review of New Day Behavioral Health Master Staffing Grid revealed the adult unit would require two nurses and two mental health technicians to be normally staffed for 11 to 13 patients on the unit.

Review of the hospital on-call physician calendar revealed Employee Identifier (EI) # 5 was the on-call Psychiatrist for the hospital on 10/11/24.

Hospital A had capability and capacity at the time of the transfer request from Hospital B.

Review of the credentialing file for EI # 5 revealed no documentation EI # 5 was provided education on EMTALA.

An interview was conducted on 11/5/24 at 2:38 PM with EI # 7, Director of Social Services, and on 11/5/24 at 3:20 PM with EI # 8, Director of New Day Behavioral Health, two of two staff who receive patient transfer request for New Day Behavioral Health. EI # 7 and EI # 8 both verbalized a patient would be denied for transfer to New Day Behavioral Health if the patient has an Intellectual disability or an IQ of less than 70, EI # 7 and EI # 8 both verbalized if the patient's IQ was unknown then the patient ability to function would be evaluated to see if the patient would be able to participate in the groups and/or plan of care the unit offers. EI # 7 verbalized if a referral is not accepted the referral is not kept by the hospital. EI # 8 verbalized PI # 23 was automatically excluded from transfer due to the mental retardation.

An interview conducted on 11/6/24 at 9:38 AM with EI # 5, On-call Psychiatrist during the referral of PI # 23. EI # 5 verbalized a patient with mental retardation/intellectual disability would be accepted at New Day Behavioral Health if the patient had other psychiatric issues going on besides the mental retardation/intellectual disability.

An interview conducted on 11/6/24 at 1:59 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 5 had been provided education on EMTALA.

An interview conducted on 11/6/24 at 2:05 PM with EI # 2, Chief Nursing Officer, confirmed staffing was per the Master Staffing Grid and beds were available on the unit at the time of the transfer request from Hospital B.

Review of Hospital B ED MR revealed PI # 23 presented to the ED on 10/10/24 at 6:44 PM with a chief complaint of behavioral issues. PI # 23's caregiver reported the patient had been attempting to bite family.

Review of the ED nursing assessment dated 10/10/24 at 6:52 PM revealed the patient was alert and oriented, attention-seeking, fidgeting, and manipulative.

Review of the ED Provider's Exam note dated 10/10/24 at 7:08 PM revealed the patient had been getting more agitated and violent at home. The patient had pushed and hit family, would lock doors, steal money to buy snacks which were against the patient's diabetic diet, and had a medical history of Mental Retardation and Attention Deficit Hyperactive Disorder with anger disorder.

Further review of the ED Provider's Exam note dated 10/10/24 at 7:08 PM revealed physical assessment findings of the patient being hard of hearing but able to talk, not currently violent, slightly agitated, and talkative but easily redirected. Further review revealed assessment findings of Oppositional Defiant Disorder (Behavior condition characterized by a persistent pattern of negative, defiant, and hostile behaviors towards peers, parents and authority figures), Agitation, and Violent Behavior with a plan to attempt to transfer to a mental health facility.

Review of the ED nursing note dated 10/11/24 at 2:44 AM revealed Hospital A (Dale Medical Center) was contacted for transfer of PI # 23 to hospital A. Further review revealed Hospital A requested PI # 23's MR be faxed to the hospital and the social worker would evaluate the MR in the morning. There was no documentation on the final decision of Hospital A.

Review of the ED MR revealed no documentation of PI # 23's IQ, or that an IQ test had been performed.

Review of the nursing note dated 10/11/24 at 7:46 AM revealed after attempting to find placement at multiple inpatient facilities the patient would be discharged home with family.

Review of the nursing note dated 10/11/24 at 9:02 AM revealed the patient was discharge home and the caregiver was encouraged to take the patient to "...mental health today or Monday."

Hospital A failed to ensure PI # 23, who had an identified psychiatric emergency condition and required the specialized capabilities of hospital A, was transferred when Hospital A had the capacity and specialized capabilities required to admit and treat PI # 23.

2. Review of Hospital A's, Dale Medical Center, transfer request log revealed a request for transfer was received from Hospital C (transferring hospital) on 10/31/24 (no time documented) for PI # 24. Further review revealed PI # 24 was denied due to "intellectually disabled."

Review of the New Day Behavioral Health Adult Unit Bed Census from 10/31/24 at 9:30 AM to 10/31/24 at 1:00 PM, revealed the 13-bed unit had one beds available until 10:45 AM. Further review revealed three patients were discharged from the unit between 10:45 AM and 11:15 AM, which would have provided four total beds available on the unit.

Further review of the New Day Behavioral Health Adult Unit Bed Census from 10/31/24 at 9:30 AM to 10/31/24 at 1:00 PM, revealed the unit was staffed with two nurses and one mental health technician.

Review of New Day Master Staffing Grid revealed the adult unit would require one nurse and one mental health technician with a census of four to six patients and two nurses and two mental health technicians with a census of seven to be normally staffed on the unit.

Review of the hospital on-call physician calendar revealed EI # 6 was the on-call Psychiatrist for the hospital on 10/31/24.

Hospital A had capability and capacity prior to the denial of PI # 24's transfer request from Hospital C.

Review of the credentialing file for EI # 6 revealed no documentation EI # 6 had be provided education on EMTALA.

An interview conducted on 11/6/24 at 9:54 AM with EI # 6, On-call Psychiatrist for PI # 24. EI # 6 verbalized a patient with mental retardation/intellectual disability would be accepted at New Day if the patient had other psychiatric issues going on besides the mental retardation/intellectual disability. EI # 6 also verbalized a patient with an IQ of 70 would be able to participate in the unit activities.

An interview conducted on 11/6/24 at 1:59 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 6 had been provided education on EMTALA.

An interview conducted on 11/6/24 at 2:05 PM with EI # 2, Chief Nursing Officer, confirmed staffing was per the Master Staffing Grid and beds were available on the unit prior to the denial of PI # 24's transfer request from Hospital C.

Review of the Hospital C's ED MR revealed PI # 24 presented to ED on 10/29/24 at 3:48 PM with a chief complaint per the patient's caregiver of being delusional, shutdown, aggressive, and refusing to speak.

Review of the ED Psychiatric Screening Exam dated 10/29/24 at 4:22 PM revealed the patient had a history of moderate intellectual disability and presented to the ED with complaints of the patient shutting down, being delusional, acting aggressively, making homicidal threats against other residents of the group home where the patient resides, and decreased talking. The character of the symptoms was documented as homicidal threats, periods of agitation and appeared to be shutting down and mumbling to self and others.

Further review of the ED Psychiatric Screening Exam dated 10/29/24 at 4:22 PM revealed physical assessment findings of the patient being cooperative, alert, and oriented to person, place, time, and situation. Further review revealed diagnoses of Homicidal Thoughts and Acute Psychosis with an order to transfer the patient to an acute psychiatric facility.

Review of Hospital C's Transfer Center Call Summary dated 10/31/24 at 9:41 AM revealed Hospital A (Dale Medical Center) was contacted for transfer of PI # 24 to hospital A. Further review revealed PI # 24 was declined by Hospital A at 12:30 PM.

Review of the ED MR revealed no documentation of PI # 24's IQ, or that an IQ test had been performed.

Review of the ED Provider note dated 11/2/24 at 2:20 AM revealed there was no accepting facility for transfer and the patient would be discharged home with caregiver.

Review of the ED Discharge Information revealed the patient was discharged home on 11/2/24 at 10:30 AM.

Hospital A failed to ensure PI # 24, who had an identified psychiatric emergency condition and required the specialized capabilities of hospital A, was transferred when Hospital A had the capacity and specialized capabilities required to admit and treat PI # 24.