HospitalInspections.org

Based on medical record review and staff interview on 11/18/11 and 11/19/11 it was determined the hospital emergency department failed to treat and stabilize one of 20 sampled patients (#17) prior to transferring the patient to another hospital for psychiatric treatment.

Findings include:

Review of the medical record on 11/18/11 revealed Patient #17 presented to the emergency department (ED) two times on the morning of 11/08/11. The patient first presented to the ED at 2:50 AM with a chief complaint of assault and multiple cuts to the face. The patient was assessed during this time for suicide risk and was determined to have a score of 2 (low risk). The patient was appropriately treated and discharged in stable condition to home at 4:22 AM.

At 4:50 AM on 11/08/11, the patient was found in the emergency turn around lot, threatening to cut his/her neck with a broken bottle. According to documentation in the medical record the patient did self inflict an abrasion to his/her neck with a broken bottle. Patient #17 was agitated and combative and the city police was called by hospital staff. Patient #17 was taken into the emergency department, restrained in a bed and the patient's neck abrasion was treated. A suicide risk assessment during this visit determined the patient was now a high risk for suicide.

The hospital allowed the patient to be transferred to the receiving hospital without first treating and stabilizing the patient's acute psychiatric condition. The hospital failed to document the risks and benefits of transfer, and failed to ensure the physician called the receiving hospital to establish a bed was available.