The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record review, the hospital failed to ensure that a patient who presented on two separate occassions to the emergency department (ED) with signs of a psychiatric disorder received on-going monitoring while awaiting transfer to another hospital for potential psychiatric admission.

Findings include:

Visit #1
Based on review of the medical record on 04/29/2015, a [AGE] year old patient was sent to the ED on 02/03/2015 at 2:12 PM by her outpatient mental health provider. She has a history of schizophrenia and bipolar disorder. She was brought to the ED by the police after running away from her outpatient appointment while threatening suicide. The patient was triaged on 02/03/2015 at 2:14 PM.

A medical screening examination (MSE) was initiated on 02/03/2015 at 3:01 PM and completed on 02/03/2015 at 4:41 PM by ED physician #1. ED physician #1 ordered a mental health evaluation. The mental health evaluation was completed by a mental health counselor on 02/03/2015 at 5:00 PM. In consult with ED physician #1 it was determined that the patient was in need of in-patient admission. This hospital does not have inpatient psychiatric capabilities. ED physician #1 spoke with the patient on 02/03/2015 at 6:37 PM and discussed his recommendations of in-patient psychiatric care. There are no further progress notes documenting clinical evaluation by medical staff.

ED physician #2 ordered medication for the patient on 02/04/2015 at 10:48 AM. It is noted in the medical record on 02/04/2015 at 12:48 PM by ED physician #2 that the patient presented to the ED with a complaint of suicidal ideation. There is no documentation that ED physician #2 spoke with or evaluated the patient.

On 02/04/2015 the patient was given medication for: psychosis (Abilify) at 10:48 AM; medication side effects (Benzotropine) at 10:48 AM; urinary tract irritation (Pyridium) at 12:22 PM; infection (Cipro) at 10:36 AM; and anxiety (Ativan) at 4:54 PM.

On 02/05/2015 the patient was medicated for: acid reflux (Protonix) at 10:34 AM; medication side effects (Benzotropine) at 10:44 AM; constipation (Colace) at 10:34 AM; anxiety (Ativan) at 10:34 AM; infection (Cipro) at 10:36 AM; and psychosis ( Abilify) at 10:44 AM.

The patient remained in the ED until 02/05/2015 at 11:22 AM, the time of transfer to another hospital.

The patient was in the ED from 02/03/2015 at 2:14 PM to 02/05/2015 at 11:22 AM, forty-five hours. After the medical screening exam was completed, there was no documentation of any ongoing monitoring by a physician for the rest of the time the patient remained in the ED.

Visit #2
Based on medical record review on 04/29/2015, the same patient returned to the ED on 02/20/2015. The patient was triaged on 02/20/2015 at 10:06 PM. She was escorted by the police. Police reported that the patient had a history of mental illness, had run away from home and when returned to her home, the patient threatened suicide.

A medical screening exam (MSE) was initiated by ED physician #3 on 02/20/2015 at 10:08 PM and completed at 11:01 PM. ED physician #3 diagnosed the patient with suicidal ideation and ordered a mental health evaluation. The mental health evaluation was completed by a mental health counselor on 02/21/2015 at 1:30 AM. At 1:55 AM, the mental health counselor recommended that the patient be admitted to a hospital for in-patient psychiatric care.

On 02/21/2015 at 7:03 AM, ED physician #3 relinquished care of the patient to the oncoming ED physician #4. There is no further documentation by medical staff indicating that the patient received ongoing monitoring and that her condition was stable. On 02/21/2015 at 12:37 PM the patient was accepted for transfer at another hospital. On 02/21/2015 at 1:36 PM the patient was transferred.

There is no documentation of monitoring by a physician after the 11:01 PM progress note written on 02/20/2015. The patient was transferred 14 hours later.