Based on policy review, medical record review and interview, the hospital failed to obtain a properly executed consent for outpatient services for 7 of 7 (Patient #1, 2, 3, 4, 5, 6 and 7) sampled patients. The findings included: 1. Review of the facility policy, Patient Access, revealed, ...PURPOSE: To ensure that applicable state and federal laws and signature requirements are followed regarding obtaining signatures on all registration forms, including the Conditions of Admission and Consent for Outpatient Services...The Patient Access Department obtains signatures on all registration forms...Each facility will establish an appropriate process for follow up and obtainment of patient signatures. Any exceptions to this policy must be documented in [computer system] collection notes...Standard forms required at time of Pre-Registration or Registration...The Conditions of Admission and Consent for Outpatient Services... Review of the facility policy, Informed Consent, revealed, ...PURPOSE: Informed consent is not merely a signed document. It is a process that considers patient needs and preferences, compliance with law and regulation, and patient education. Utilizing the informed consent process helps the patient to participate fully in decisions about his or her care, treatment, and services...A properly informed consent form contains the following minimum elements...Signature of the patient or the patient's legal representative... 2. Medical record review for Patient #1 revealed the dates of registration for outpatient services were 11/16/2020 and 11/20/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #1's handwritten printed initials]...Signature required 11/16/2020 11:14 AM... There was no documentation Patient #1 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 11:14 AM. The [name of hospital] STRESS TESTING INFORMED CONSENT dated 11/20/2020 revealed Patient #1 did not sign the informed consent for the treadmill nuclear stress test. The informed consent was documented as witnessed by Registered Nurse #1 on 11/20/2020 at 11:50 AM. The Myocardial Perfusion Imaging Report and NUCLEAR MYOCARDIAL PERFUSION STUDY dated 11/20/20 confirmed the treadmill nuclear stress test was performed on Patient #1 on 11/20/2020. In a phone interview on 1/22/2021 at 2:11 PM, Patient #1 stated she went to the desk at the cardiac office to check-in for a cardiac stress test on 11/16/2020 a little after 11:00 AM. Patient #1 stated the person behind the desk took her name and told her to wait in the waiting room. Patient #1 stated that while she was waiting, she received an email to register for her appointment. Patient #1 stated she attempted to fill out the consent form but could not complete the form. Patient #1 stated she was called to the back, and she exited out of her email without saving the form she had signed. Patient #1 stated she was informed that she could not have the procedure done because she drank coffee earlier that morning. Patient #1 stated she checked her email after she arrived back home and found that the Conditions of Admission and Consent for Outpatient Care form had been completed with handwritten printed initials, but the initials were not in her handwriting and had not been put there by her. In a phone interview on 1/26/2021 at 8:09 AM, Patient #1 stated she rescheduled the cardiac stress test for 11/20/2020. Patient #1 stated she printed out the consent form and showed them to Registrar #1 after she signed a hard copy of the Conditions of Admission and Consent for Outpatient Care. Patient #1 stated Registrar #1 confirmed the initials on the Conditions of Admission and Consent for Outpatient Care form dated 11/16/2020 were not hers. Patient #1 stated she always signed all three of her initials, she never printed her initials, and she always signed her name when a signature was required. The form had two printed initials from the first and last name in each box for initials and signature. There was no signature of Patient #1 on the form. Patient #1 stated she remembered seeing Registrar #1 at the check-in desk on 1/16/2020 but stated Registrar #1 did not go over any forms with her or have her sign any forms. Patient #1 stated no one at the check-in desk asked her to sign any forms on 11/16/2020. 3. Medical record review for Patient #2 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #2's handwritten printed initials]...Signature required 11/16/2020 07:14 AM... There was no documentation Patient #2 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 7:14 AM. The TRANSTHORACIC ECHOCARDIOGRAM report dated 11/16/2020 confirmed a transthoracic echocardiogram was performed on Patient #2 on 11/16/2020. In a phone interview on 1/26/2021 at 12:36 PM, Patient #2 stated she did not remember signing any forms, either hard copy or electronic, at the check-in desk for her procedure on 11/16/2020. 4. Medical record review for Patient #3 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #3's handwritten printed initials]...Signature required 11/16/2020 07:18 AM... There was no documentation Patient #3 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 7:18 AM. The ECHOCARDIOGRAM REPORT dated 11/16/2020 confirmed an echocardiogram was performed on Patient #3 on 11/16/2020. 5. Medical record review for Patient #4 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #4's handwritten printed initials]...Signature required 11/16/2020 07:38 AM... There was no documentation Patient #4 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 7:38 AM. The ECHOCARDIOGRAM REPORT and CARDIAC STRESS TEST report dated 11/16/2020 confirmed an echocardiogram and stress test were performed on Patient #4 on 11/16/2020. 6. Medical record review for Patient #5 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #5's handwritten printed initials]...Signature required 11/16/2020 08:07 AM... There was no documentation Patient #5 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 8:07 AM. The TRANSTHORACIC ECHOCARDIOGRAM report dated 11/16/2020 confirmed a transthoracic echocardiogram was performed on Patient #5 on 11/16/2020. 7. Medical record review for Patient #6 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #6's handwritten printed initials]...Signature required 11/16/2020 08:30 AM... There was no documentation Patient #6 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 8:30 AM. The TRANSTHORACIC ECHOCARDIOGRAM report dated 11/16/2020 confirmed a transthoracic echocardiogram was performed on Patient #6 on 11/16/2020. 8. Medical record review for Patient #7 revealed the date of registration for outpatient services was 11/16/2020. The Conditions of Admission and Consent for Outpatient Care dated 11/16/2020 revealed, ...Patient/Patient Representative Signature: [Patient #7's handwritten printed initials]...Signature required 11/16/2020 12:40 PM... There was no documentation Patient #7 signed the form. The Conditions of Admission and Consent for Outpatient Care was documented as electronically witnessed by Registrar #1 on 11/16/2020 at 12:40 PM. The ECHOCARDIOGRAM REPORT dated 11/16/2020 confirmed an echocardiogram was performed on Patient #7 on 11/16/2020. In a phone interview on 1/26/2021 at 12:01 PM, Patient #7 stated she did not sign any forms at the check-in desk on 11/16/2020 for her echocardiogram. Patient #7 stated she thought it was odd not to sign a consent form, but no one asked her to sign anything. 9. In an interview in the conference room on 1/19/2021 at 10:35 AM, the Patient Access Director stated each patient who presented to the cardiovascular outpatient diagnostic office should have a face to face meeting with the registrar and sign any paperwork on an Ipad. The Patient Access Director stated the registrar should get a patient's signature for the Conditions of Admission and Consent for Outpatient Care form where indicated and confirm the signature of the patient or patient's representative.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policy, medical record review, and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated the weight and oral intake for each patient for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of the hospital's policy Evidenced Based Clinical Documentation: Documenting Standard of Care revealed, ...ASSESSMENT AND REASSESSMENT...Registered Nurses [RN] perform and document assessments...RNs are responsible for reviewing and analyzing the data, drawing conclusions and taking appropriate actions...CARE ACTIVITIES...Vital signs/ht [height] & [and] wt [weight]/measurements... Review of the hospital's policy Appendix A Clinical Assessment, Reassessment, and Plan of Care, revealed, ...Area...[named psychiatric unit]...Weight...Upon admission, every Sunday, and Per Provider Order... 2. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Senile Dementia of the Alzheimer's Type, Complicated by Behavioral Disturbance and Psychosis, Hypertension, and Urinary Tract Infection. The CLINICAL DOCUMENTATION RECORD dated 10/19/20 at 6:28 PM revealed Patient #1's weight was documented as 44 kilograms (kg) (96.8 lbs) per bed scale. The CLINICAL DOCUMENTATION RECORD dated 10/22/20 at 6:19 AM revealed Patient #1's weight was documented as 44 kg. The CLINICAL DOCUMENTATION RECORD dated 10/25/20 at 5:06 PM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs) per bed scale. The CLINICAL DOCUMENTATION RECORD dated 10/27/20 at 6:31 AM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs). The CLINICAL DOCUMENTATION RECORD dated 10/29/20 at 6:11 AM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs). The CLINICAL DOCUMENTATION RECORD dated 11/1/20 at 6:27 PM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs) per bed scale. There was a 12.6 kg (27.72 lbs) difference between this weight and the weights documented on 10/19/20 and 10/22/20. There was a 12.3 kg (27.06 lbs) difference in this weight and the weights documented on 10/25/20, 10/27/20 and 10/29/20. The CLINICAL DOCUMENTATION RECORD dated 11/3/20 at 7:00 AM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs). The CLINICAL DOCUMENTATION RECORD dated 11/5/20 at 6:24 AM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs). There was no documentation Patient #1 was weighed on 11/8/20 (Sunday) as indicated per policy. There was no documentation the weights (31.4 kg/69.08 lbs) documented on 11/1/20, 11/3/20 and 11/5/20 were addressed as aberrant weights or actual weight loss. The CLINICAL DOCUMENTATION RECORD dated 11/10/20 through 11/12/20 revealed Patient #1 ate 25% of lunch on 11/10/20. Patient #1 consumed less than 10% of all meals from 11/10/20 through 11/12/20 except for lunch on 11/10/20. There was no documentation nursing staff addressed or notified the physician of the decreased oral intake. 3. Medical record review from Hospital #2 revealed Patient #1's weight was documented on 11/13/20 at 12:54 AM as 37.1818 kg (81.8 lbs) per bed scale. This weight was 6.8182 kg (15 lbs) less than Patient #1's weight documented on 10/19/20 and 10/22/20 and 6.5182 kg (14.34 lbs) less than Patient #1's weight documented on 10/25/20, 10/27/20 and 10/29/20. 4. In a phone interview on 11/24/20 at 12:35 PM, Nurse Practitioner #1 stated the providers were dependent on nursing staff to inform them of any weight loss or if a patient was not eating adequately. Nurse Practitioner #1 stated no one communicated to her that there was a problem with Patient #1's weight or her oral intake. In a phone interview on 11/24/20 at 12:34 PM, the Manager of the Memory Care Unit stated the Patient Care Technicians were supposed to weigh each patient every Sunday. The Manager of the Memory Care Unit stated if there was a significant weight loss or an aberrant weight, the system would send the Pharmacist a message. The Pharmacist could ask staff to reweigh the patient if concerned about the weight being an error. If there was an actual weight loss, there should be a nutritional consult. We did not have a concrete process to review weights and make sure all the weights were done.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, hospital document review, video footage review and interview, the hospital failed to thoroughly investigate an allegation of neglect for 1 of 3 (Patient #1) sampled patients. The finding included: 1. Review of the hospital's Alleged or Suspected Abuse (Child and/or Adult) policy revealed, ...Types of Abuse...Neglect includes both physical and emotional types of omissions. Neglect includes...failure to provide supervision...` 2. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Schizophrenia, Alcohol Use Disorder, Cannabis Use Disorder, Homicidal Ideation and Suicidal Ideation. A Clinical Note dated 10/5/18 revealed, ...I [Physician #1] responded to a code blue overhead. on arrival, active compressions being perform ACLS [advanced cardiac life support] per protocol initiated...initial rhythm was asystole...there was no ROSC [return of spontaneous circulation] achieved. i pronounced patient expired at 0808 [8:08 AM]... The Discharge Summary dated 10/17/18 revealed, ...Patient was admitted to [Psychiatric Unit] due to worsening of mood and polysubstance abuse. Patient has a history of benzodiazepine abuse and was placed on the CNS [central nervous system] protocol by the tele psych on the morning of October 4th. He received 4 doses of phenobarbital after which the CNS protocol was discontinued due to sedation as per protocol. Patient was seen by attending physician on noon of October 4th and it was observed that patient was sedated due to phenobarbital load at which time the CNS protocol was officially discontinued. Later that evening the patient was observed on the unit interacting with peers and staff appropriately...The following morning nursing staff discovered the patient unresponsive at 7:50 AM. Rapid response team was called and code blue protocol was observed...Patient was pronounced dead by [Physician #1] at 8:08 a.m. Afterwards multiple peers on the same unit came forward informing staff that the deceased had offered them Xanax the previous night. Staff search[ed] the patient's room [after Patient #1 pronounced dead] and found two Xanax [benzodiazepine] tabs [tablets] as well as two Subutex [narcotic] tabs in the patient's belongings. It is unclear when and how the patient gained access to the contraban[d] medications. It was observed after the fact that the patient's issues [shoes] contained hidden compartments ... 3. Review of the Executive Summary (summary of debriefing meeting held by the hospital after Patient #1's death, not dated) revealed, ...10/4/18 ...06:32 [6:32 AM]...Belonging assessment reviewed on tape and noted to be thorough...10/5/18...8:10 [AM]...During clean up loose pills were found in the room. (2 X [times] 2gm [gram, pills identified by pharmacy as 2 milligrams rather than 2 grams] Xanax, 1 subutex) In addition, he had a hole in the inside of his shoe under the insole that he could have concealed drugs on admission... Review of the video footage of the belonging assessment for Patient #1 revealed the footage was partially blocked by two video screens, and the camera was approximately 30 feet away from the actual belonging assessment. The video footage revealed Mental Health Associate (MHA) #2 wrote down the personal items on a piece of paper, but there was no documentation of personal belongings in Patient #1's medical record. The personal belongings search was conducted by one staff member (hospital policy required either staff and patient or two staff members). The hidden compartment in Patient #1's shoe was not found during the personal belongings search. The hospital concluded the belonging assessment was thorough, but the assessment was not performed according to hospital policy and failed to identify the hidden compartment in Patient #1's shoes. 4. Review of the Executive Summary revealed the hospital reviewed the video footage and determined the nurse/technician (tech) did not actually go into the room on several occasions after 5:00 AM on 10/5/18. The video footage was not kept, and there was no documentation when staff entered the room after 5:00 AM. During an interview in the Ethics and Compliance Office on 12/10/18 at 2:00 PM, the Director of Nursing for Senior Services was asked when did a staff member last enter Patient #1's room before he was found unresponsive and pulseless by another patient on 10/5/18 at 7:40 AM, she stated the tech entered the room on 10/5/18 at 7:15 AM. The Director of Nursing for Senior Services stated she determined this when she and the Nurse Manager of the Adult Treatment Program interviewed Contract MHA #1. The Director of Nursing for Senior Services confirmed there was no documentation of the interview, no documentation of the time when Contract MHA #1 last entered the room, and the video footage had not been kept. During a phone interview on 11/27/18 at 1:18 PM, Contract MHA #1 stated she could not remember the time she last went into Patient #1's room on 10/5/18. 5. The Executive Summary revealed, ...Patient was found on stomach, pulseless and was cold, rigid, mottled extremities and red faced ... There was no documentation by the hospital how this information was provided or where it came from. During an interview in the Ethics and Compliance Office on 11/28/18 at 9:00 AM, the Vice President of Quality stated she did not know who made this statement or where the information came from. During an interview in the Ethics and Compliance Office on 11/27/18 at 10:00 AM, Registered Nurse (RN) #5 (first staff to witness unresponsive patient), stated he could not recall the condition of the body when he entered the room on 10/5/18. During an interview in the Ethics and Compliance Office on 11/28/18 at 10:56 AM, Physician #2 stated the staff had already begun chest compressions when he entered Patient #1's room on the morning of 10/5/18. Physician #2 stated he was sort of QBing (quarterbacking) and making sure the team had all the necessary equipment. When asked if he ever touched the body, Physician #2 stated he checked for a pulse and a blood pressure. Physician #2 stated he was not struck that the body was cold, but the body became cold as the code went on. The documentation of the code revealed the code lasted 11 minutes (from 7:55 AM to 8:06 AM). During an interview in the Ethics and Compliance Office on 12/10/18 at 11:00 AM, when asked about the statement that the body was found cold, rigid, mottled extremities and red faced, the Vice President of Quality stated the statement was inaccurate. When asked when did they (hospital staff) determine the statement to be false, the Vice President of Quality stated after this surveyor's interviews with the staff. The hospital was unable to provide any documentation or evidence about the condition of the body when it was found. The hospital dismissed its own findings after the surveyor conducted an investigation into the condition of the body. 6. The Executive Summary revealed Contract MHA #1, who documented she rounded on Patient #1 on 10/5/18 from 5:00 AM to 7:00 AM, was terminated after review of the video footage during that timeframe and interview with Contract MHA #1. According to the summary, the video footage revealed the tech did not round each time she documented but was at the front desk. The hospital was unable to provide documentation of the interview with Contract MHA #1 or the video footage. During an interview in the Ethics and Compliance Office on 12/10/18 at 2:00 PM, the Director of Nursing for Senior Services stated she and the Nurse Manager of the Adult Treatment Program interviewed Contract MHA #1 and reviewed the video footage. The Director of Nursing for Senior Services confirmed there was no documentation of the interview, and the video footage was not available. When asked what time was the last time Contract MHA #1 was in Patient #1's room on 10/5/18, the Director of Nursing for Senior Services stated 7:15 AM. There was no documentation provided by the hospital that indicated when Contract MHA #1 did or did not enter Patient #1's room on 10/5/18 from 5:00 AM to 7:00 AM. The hospital added to the intake information on 1/11/19 that Contract MHA #1 did not enter the room during this time on 4 separate occasions. This information was not provided to the surveyor during the investigation, and there was no documentation provided which indicated Contract MHA #1 did not enter Patient #1's room 4 times. 7. During an interview in the Ethics and Compliance Office on 11/28/18 at 9:00 AM, the Vice President of Quality presented a document entitled Executive Summary. The Vice President of Quality stated this was the hospital's investigation for the incident of Patient #1's death and was a summary of the debriefing meeting which the hospital used to conduct the Serious Event Analysis. The Vice President of Quality confirmed there were no documented interviews or documented personnel in the summary presented to the state surveyor. During an interview in the Ethics and Compliance Office on 11/29/18 at 7:45 AM, the Manager of Quality Improvement stated the hospital conducted a Serious Event Analysis to determine what happened during the incident with Patient #1. The Manager of Quality Improvement stated the hospital staff who conducted the meeting did not write down what anyone said or who said what. The Manager of Quality Improvement stated several people might have been talking at one time during the debriefing, and no one documented who was there or what each person said. The Manager of Quality Improvement stated they did not interview anyone separately to investigate the incident.
Based on personnel file review and interview, the hospital failed to ensure staff was adequately educated and trained for 5 of 5 (Registered Nurse (RN) #1, 2, 3, 4 and 5) sampled registered nurses and 4 of 4 (Mental Health Associate (MHA) #1, 2, 3 and 4) sampled mental health associates. The findings included: 1. Review of the facility's Competency Assessment policy revealed, ...SCOPE...Applies to all employees...PURPOSE...To define mechanisms used to assess and maintain competency of employees as required for the position and by regulatory agencies...DEFINITIONS...Competency: A competency refers to the knowledge, skills, abilities, and behaviors required to perform assigned duties and responsibilities safely and aptly...Competency Assessment: Competency assessment is conducted initially as a part of orientation. Ongoing competency assessment occurs at a minimum annually...RESPONSIBILITIES...Management is responsible for ensuring a mechanism exists to identify area-specific competency requirements; creating an environment that promotes timely competency assessment and ongoing growth and development; providing education to employees on the competency process; monitoring employee progress; and participating in evaluation of the competency process...The initial competency assessment will include, at a minimum, the validation of core competencies specific to the role and responsibility of each position or position type...Ongoing competency assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking... 2. Review of the personnel file for RN #1 revealed a date of hire of 10/5/15. There was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for RN #2 revealed a date of hire of May 2017. There was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for RN #3 revealed a date of hire of 9/1/95. There was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for RN #4 revealed a date of hire of 7/19/10. There was no documentation of education, training or competencies provided by the hospital since her orientation in 2010. Review of the personnel file for RN #5 revealed there was no documentation of education, training or competencies provided by the hospital. 3. Review of the personnel file for MHA #1 revealed there was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for MHA #2 revealed a date of hire of 11/16/15. There was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for MHA #3 revealed a date of hire of 2/27/04. There was no documentation of education, training or competencies provided by the hospital. Review of the personnel file for MHA #4 revealed there was no documentation of education, training or competencies provided by the hospital. 4. During an interview in the Ethics and Compliance Office on 11/27/18 at 12:44 PM, when asked about annual training for the staff of the mental health units, the Director of Nursing for Senior Services stated, ...we don't do annual competencies... The Director of Nursing stated there was no documentation for the training the mental health associates received for the belongings search and rounding. During an interview in the Ethics and Compliance Office on 11/28/18 at 12:41 PM, the Clinical Educator for (Psychiatric Facility in hospital) stated she covered the suicide prevention class with new employees during orientation but did not provide any formal annual training to staff.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, video footage review, hospital documents and interview, the hospital failed to assess a patient at risk for suicide and violent behavior for 3 of 3 (Patient #1, 2 and 3) sampled patients. The findings included: 1. Review of the hospital's Assessment and Management of Violent Patients policy revealed, ...POLICY...All patients admitted to the (Psychiatric Unit) will be assessed at the time of admission for current risk of violence as well as history of violent behavior...All patients admitted to the (Psychiatric Unit) will be continuously reassessed using the Broset Violence Checklist...PROCEDURE...Initial Broset scores will be obtained during the intake assessment or on the unit if patient is a direct admit. Afterwards, the staff will obtain Broset scores every four while awake for the first twenty-four... Review of the hospital's Admission and Post-Admission Search of Patient Belongings policy revealed, ...PURPOSE: To provide guidelines for admission searches which ensure the safety of all patients while promoting dignity and personal responsibility... PROCEDURE...Upon arrival to the unit, nursing staff will take the patient and the patient's possessions into a conference or treatment room for the search...staff will search belongings in patient's presence and not leave patient alone with their personal possessions. Possessions will not be left unattended until the search is completed. If the patient is unable to participate in the belongings inventory, two staff members will inventory together and sign...Nursing personnel will...Thoroughly search luggage, shoes, wallets, purses, cosmetic bags, etc. All items carried on the person or brought into the hospital must be checked and logged in on admission search sheet... 2. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Schizophrenia, Alcohol Use Disorder, Cannabis Use Disorder, Homicidal Ideation and Suicidal Ideation. The NURSING ADMISSION CHECKLIST dated 10/4/18 revealed, ...Complete Safety/Risk/Regulatory Checklist: Broset...1st hour - Golden hour...Every four hours for the first 24 hours - Bronze hours... The initial Broset score was assessed upon arrival to the unit from the emergency department on 10/4/18 at 6:22 AM. The Broset score was assessed on 10/4/18 at 10:31 AM and 7:30 PM. There were no other assessments of Broset scores documented during Patient #1's first 24 hours. During a phone interview on 11/27/18 at 12:01 PM, when asked how often should the nurse assess the Broset score after a patient was admitted , Registered Nurse (RN) #1 stated, ...we do it once a shift (shift is either 7:00 AM-7:00 PM or 7:00 PM to 7:00 AM which is 12 hours long)... During a phone interview on 11/28/18 at 8:03 AM, when asked how often should the nurse assess the Broset score after a patient was admitted , RN #4 stated, ...once per shift... There was no documentation of a personal belongings search maintained in Patient #1's medical record. The Discharge Summary dated 10/17/18 revealed, ...Staff search[ed] the patient's room [after Patient #1 pronounced dead] and found two Xanax [benzodiazepine] tabs [tablets] as well as two Subutex [narcotic] tabs in the patient's belongings. It is unclear when and how the patient gained access to the contraban[d] medications. It was observed after the fact that the patient's issues contained hidden compartments... Review of the Executive Summary (summary of debriefing meeting held by the hospital after Patient #1's death, not dated) revealed, ...10/5/18...8:10 [AM]...During clean up loose pills were found in the room. (2 X [times] 2gm [gram, pills identified by pharmacy as 2 milligrams rather than 2 grams] Xanax, 1 subutex) In addition, he had a hole in the inside of his shoe under the insole that he could have concealed drugs on admission... Review of the video footage of the belongings search for Patient #1 revealed the footage was partially blocked by two video screens, and the camera was approximately 30 feet away from the actual belonging assessment. The video footage revealed Mental Health Associate (MHA) #2 wrote down the personal items on a piece of paper, but there was no documentation of personal belongings in Patient #1's medical record. The personal belongings search was conducted by one staff member (hospital policy required either staff and patient or two staff members). The hidden compartment in Patient #1's shoe was not found during the personal belongings search. During a phone interview on 11/27/18 at 12:09 PM, when asked how she would check a patient's shoes during the personal belongings search, MHA #1 stated, ...put my hand down inside the shoe... During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked if it was appropriate for a staff member to put their hand down inside a patient's shoe during the belongings search, the Director of Nursing for Senior Services stated, ...no ... The Director of Nursing for Senior Services confirmed there was no documentation for the personal belongings search for Patient #1. 3. Medical record review for Patient #2 revealed an admission date of [DATE] with diagnoses which included Major Depressive Disorder, Borderline Personality Features, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. The Non Hazard Items and Hazard Items dated 10/4/18 revealed an inventory of Patient #2's belongings with each form signed by the patient and a staff member. A plain sheet of paper dated 10/4/18 contained a separate handwritten list of personal items not signed by anyone. The handwriting on the plain sheet of paper was different than the other two lists. During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked about the unsigned list of personal items, the Director of Nursing for Senior Services stated she could not tell what happened with the belongings search for Patient #2 and confirmed the search was not done appropriately. 4. Medical record review for Patient #3 revealed an admission date of [DATE] with diagnoses which included Bipolar Depression, History of Posttraumatic Stress Disorder, and Diabetes Mellitus. The Non Hazard Items and Hazard Items forms for documented the personal belongings search were blank. There was a plain sheet of paper dated 10/10/18 with a list of personal items. The list was not signed by anyone. During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked about the unsigned list of personal items, the Director of Nursing for Senior Services confirmed the personal belongings search was not done appropriately for Patient #3.
Based on policy review, personnel file review and interview, the hospital failed to ensure adequate supervision and evaluation of the clinical activities of non-employee nursing personnel for 1 of 1 (Contract Mental Health Associate (MHA) #1) sampled contract nursing personnel. The findings included: 1. Review of the hospital's Competency Assessment policy revealed, ...SCOPE...Contract staff will be held to the same standards as employees and the records must be maintained by the business entity...PURPOSE...To define mechanisms used to assess and maintain competency of employees as required for the position and by regulatory agencies...DEFINITIONS...Competency: A competency refers to the knowledge, skills, abilities, and behaviors required to perform assigned duties and responsibilities safely and aptly...Competency Assessment: Competency assessment is conducted initially as a part of orientation. Ongoing competency assessment occurs at a minimum annually...RESPONSIBILITIES...Management is responsible for ensuring a mechanism exists to identify area-specific competency requirements; creating an environment that promotes timely competency assessment and ongoing growth and development; providing education to employees on the competency process; monitoring employee progress; and participating in evaluation of the competency process...The initial competency assessment will include, at a minimum, the validation of core competencies specific to the role and responsibility of each position or position type...Ongoing competency assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking... 2. Review of the personnel file for Contract MHA #1 revealed 1 completed online course dated 8/21/17 and 2 completed online courses dated 8/22/17. The course subjects included code of conduct, orientation for clinical staff and regulatory compliance. There was no documentation of education, training or competencies which specifically addressed providing care for behavioral health patients. 3. During an interview in the Ethics and Compliance Office on 11/27/18 at 12:44 PM, when asked about annual training for the staff of the mental health units, the Director of Nursing for Senior Services stated, ...we don't do annual competencies... The Director of Nursing stated there was no documentation for the training the mental health associates received for the belongings search and rounding. During a phone interview on 11/27/18 at 1:18 PM, Contract MHA #1 stated she started working in the psychiatric unit of the hospital in August of 2017. Contract MHA #1 stated she left in November 2017 on maternity leave and re-signed to work in the psychiatric unit of the hospital in August 2018. Contract MHA #1 stated she was supposed to receive training when she re-signed but never received training. During an interview in the Ethics and Compliance Office on 11/28/18 at 12:41 PM, the Clinical Educator for (Psychiatric Facility in hospital) stated the hospital did not provide orientation to contract staff. The Clinical Educator stated the contract staff does not go through the hospital for education and training.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of 42 Code of Federal Regulations (CFR) 489.102, policy review, medical record review and interview, the hospital failed to inform the patient's representative of the patient's rights in advance of discontinuing patient care for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of 42 CFR 489.102 revealed, ...Hospitals...must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care...by or through the provider and are required to...Provide written information to such individuals concerning...An individual's rights under State law...to make decisions concerning such medical care...The written policies of the provider or organization respecting the implementation of such rights, including a clear and precise statement of limitation if the provider cannot implement an advance directive on the basis of conscience. At a minimum, a provider's statement of limitation should...(A) Clarify any differences between institution-wide conscience objections and those that may be raised by individual physicians; (B) Identify the state legal authority permitting such objection; and (C) Describe the range of medical conditions or procedures affected by the conscience objection... 2. Review of the hospital's Advance Directives policy revealed, ...If the attending physician cannot honor an Advance Directive, he/she should make every effort to transfer the patient to a physician who is able to honor the patient's wishes... Review of the hospital's Patient Rights policy revealed, ...PURPOSE...Ensure that all patients receiving care and/or patient representatives are informed of their rights...Ensure that this policy is in alignment with federal, state and local regulations ... 3. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Severe Sepsis with Septic Shock, End-Stage Renal Disease on Dialysis, Chronic Tracheostomy/Ventilator, Persistent Vegetative State, Diabetes Mellitus, Chronic Respiratory Failure, [DIAGNOSES REDACTED], Decubitus Ulcers, Anemia and Congestive Heart Failure. The ADVANCE CARE PLAN dated 11/20/17 revealed, ...I, [Patient #1's name], hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself...Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below...Name: [Patient #1's son]...Quality of Life: By marking yes below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management...[box checked yes]...Permanent Unconscious Condition...[box checked yes]...Permanent Confusion...[box checked yes]...Dependent in all Activities of Daily Living...[box checked yes]...End-Stage Illnesses...Treatment...By marking yes below, I have indicated treatment I want...[box checked yes]...CPR (Cardiopulmonary Resuscitation)...[box checked yes]...Life Support/Other Artificial Support...[box checked yes]...Treatment of New Conditions...[box checked yes]...Tube feeding/IV [intravenous] fluids... The physician's note dated 11/2/18 revealed, ...I [Physician #1] believe care is inappropriate and unethical at this time...I am going to stop dialysis...I believe she [Patient #1] should be hospice/comfort care only...I will discuss with son [Patient #1's Power of Attorney (POA) for Healthcare Decisions] when he arrivves [arrives] later today...Addendum 1: 11/02/18 0823 [8:23 AM]...SPOKE WITH SON BY PHONE...INFORMED SON THAT WE ARE STOPPING CARE AS WE FEEL IT IS UNETHICAL/FUTILE... There was no documentation the hospital provided Patient #1's POA for Healthcare Decisions written information concerning the written policies which included a clear and precise statement of limitation if the provider cannot implement an advance directive on the basis of conscience. 4. During an interview in the Ethics and Compliance Office on 12/10/18 at 2:45 PM, the Quality Improvement Manager stated she did not believe the hospital gave patients or their representatives the written policies for advance directives.
During an EMTALA investigation of complaint # conducted 12/11/17 to 1/8/18, Tristar Centennial Medical Center was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CRF Part 489.20 and 489.24. Based on review of facility policies, review of Medical Staff By-laws, review of Medical Staff Rules and Regulations, medical record review, review of Psychiatric On-Call schedules, and interviews, the facility failed to: 1. Ensure on call psychiatrists who were available and on call for duty performed an adequate examination and provided necessary treatment and/or services for all patient who presented to the ED with psychiatric signs and symptoms for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patient records reviewed who presented to the ED seeking treatment for psychiatric conditions. Refer to A-2404 2. Ensure an appropriate medical screening examination was performed within the capability of Hospital #1's Emergency Department (ED) and ensure patients presenting with psychiatric disorders were assessed by the hospital on call psychiatrists in order to determine if an emergency psychiatric conditions existed for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patients who presented to the ED seeking treatment for psychiatric conditions. Refer to A-2406 3. Ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 28 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10,11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26 and 27) patients who presented to the Emergency Department (ED) seeking treatment. Refer to A-2407 4. Ensure patients with identified emergency psychaitric conditions were transferred to Hospital #1's inpatient psychiatric unit which had the capacity and capability to treat the patients. The hospital failed to minimize the risks to the patients' health by allowing patients with psychaitric conditions to remain in Hospital #1's Emergency Department (ED) for lengthy periods of time without treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat patients with psychaitric conditions resulted in the inappropriate transfer of 19 of 27 (Patient's 1, 2, 4, 5, 6, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 19, 20, 21, 22, 25 and 26) patients who presented to Hospital #1's ED seeking treatment for a psychaitric condition. Refer to A-2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff on-call schedules, medical record reviews and interviews, the facility failed to ensure on call psychiatrists who were available and on call for duty performed an adequate examination and provided necessary treatment and/or services for all patient who presented to the ED with psychiatric signs and symptoms for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patient records reviewed who presented to the ED seeking treatment for psychiatric issues. The findings included: 1. Review of facility policy, EMTALA [Emergency Medical Treatment and Labor Act]- Definitions and General Requirements last reviewed 03/2013, revealed, ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs [Emergency Medical Condition] ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMCs. Only physicians that are available to physically come to the ER [emergency room ] may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA ...PROCEDURE ...A. General Requirements ...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility. 2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed ...1.B. PURPOSES AND RESPONSIBILITIES ...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and... 3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16 revealed, ... EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services: 1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ... 4. Review of Hospital #1's Medical Staff on-call Logs, for the specialty of psychiatry, revealed a Psychiatrist on-call each day for the months of January 2015 through October 2017 when 28 of 31 patients were in the ED. 5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.' The patient was uninsured. Review of the ED notes for Patient #1 revealed on 7/12/17 at 1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ... A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, ...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ... Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, [AGE]-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ... The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation. ED Physician #3's note dated 7/13/17 at 7:32 AM documented, awaiting placement at [name of Hospital #2] ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4. ED Physician #4's note dated 7/15/17 at 12:10 AM documented, This is a [AGE]-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care. ED Physician #5's note dated 7/15/17 at 6:39 AM documented, Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ... ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable. ED Physician #6's note dated 7/16/17 at 5:49 PM documented, Patient has been stable in the emergency department. He was accepted at [named hospital #2] ... Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, [AGE]-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says I'm really messed up. But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ... The patient had out of state Medicaid insurance. Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ... Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient. Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17. ED physician #4's note dated 7/15/17 at 12:04 AM documented, Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ... ED Physician #5's note dated 7/15/17 at 6:37 AM documented, Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ... ED Physician #7's note dated 7/16/17 at 4:23 PM documented, Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ... ED Physician #6's note dated 7/17/17 at 1:46 AM documented, ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]. Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility. There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter. The patient was uninsured. Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , [AGE]-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ... Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ... The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ... A nurses note dated 7/13/17 at 7:13 AM documented, Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ... A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed. Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3)for inpatient treatment. 8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured. Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, [AGE]-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ... A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list. Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of ...confused, disoriented, found walking through traffic on 440 ... The patient was uninsured. Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalization s, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ... Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, ...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, referred to Call Center/MCRT for disposition... The Emergency Department notes dated 7/16/17 at 11:16 AM documented, Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ... Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ... Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment. 10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured. Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI... Review of the CAPS behavior health assessment dated [DATE] at 4:39 PM revealed the patient was not referred to the psychiatrist on-call. Review of the emergency room Notes dated 10/11/17 at 5:11 PM documented, [Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ... The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation. ED Physician #8 dated 10/13/17 at 5:00 AM documented, ...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ... ED Physician #6's note dated 10/14/17 at 6:28 AM documented, Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ... ED Physician #4's note dated 10/16/17 at 4:09 AM documented, The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ... Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #7's psychiatric condition while the patient remained in Hospital #1's ED for 160 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid). Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, [AGE]-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk... Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, ...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT... ED physician #2 dated 8/25/17 at 5:23 AM documented, Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis. Review of the CAPS assessment dated [DATE] at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate. Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured. Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, ...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged ] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions... Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged ] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen... Further review of the nurse's notes revealed, ...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ... A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the pending board for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list. A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM. Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #10's psychiatric condition while the patient remained in Hospital #1's ED for 99 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid). Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, [AGE]-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ... Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations. A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17. Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM. ED physician #5's note dated 6/2/17 at 6:54 PM documented, Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ... Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient was in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance. Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, This is a [AGE]-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are driving him crazy. He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ... Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability. ED physician #6's note dated 6/5/17 at 5:58 AM documented, ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ... A nurse's note dated 6/5/17 at 6:44 PM documented, Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ... A nurse's note dated 6/6/17 at 1:31 PM documented, ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ... Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call schedules, medical record review and interviews, the facility failed to provide an appropriate medical screening examination within the capability of Hospital #1's Emergency Department (ED) and ensure patients presenting with psychiatric disorders were assessed by the hospital on call psychiatrists in order to determine if an emergency psychiatric conditions existed for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patients who presented to the ED seeking treatment for psychiatric conditions. The findings included: 1. Review of facility policy, EMTALA - Definitions and General Requirements last reviewed 3/2013, revealed, ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMCs. Only physicians that are available to physically come to the ER may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA... PROCEDURE... A. General Requirements... 2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual... D. On-Call Obligations: 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs... 5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility. 2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed ... 1.B. PURPOSES AND RESPONSIBILITIES... (12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and ... 3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and approved by the Board of Trustees on 6/24/16, revealed, ... IV. EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services: 1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness... 4. Review of the Medical Staff On-Call Logs, for the specialty of psychiatry, from January, 2015, through October, 2017, revealed a Psychiatrist was on-call each day during the time 29 of 31 patients were in the ED. 5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of suicidal thoughts and a plan, Pt reports 'my world is coming undone'. The patient was uninsured. Review of the ED notes for Patient #1 revealed on 7/12/17 at 1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ... A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, ...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ... Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, [AGE]-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ... The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation. ED Physician #3's note dated 7/13/17 at 7:32 AM documented, awaiting placement at [name of Hospital #2] ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4. ED Physician #4's note dated 7/15/17 at 12:10 AM documented, This is a [AGE]-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care. ED Physician #5's note dated 7/15/17 at 6:39 AM documented, Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ... ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable. ED Physician #6's note dated 7/16/17 at 5:49 PM documented, Patient has been stable in the emergency department. He was accepted at [named hospital #2] ... Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, [AGE]-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says I'm really messed up. But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ... The patient had out of state Medicaid insurance. Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ... Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient. Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17. ED physician #4's note dated 7/15/17 at 12:04 AM documented, Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ... ED Physician #5's note dated 7/15/17 at 6:37 AM documented, Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ... ED Physician #7's note dated 7/16/17 at 4:23 PM documented, Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ... ED Physician #6's note dated 7/17/17 at 1:46 AM documented, ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]. Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment of Patient #2 or stabilization treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility. There was no documentation why Patient #2 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter. The patient was uninsured. Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , [AGE]-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ... Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ... The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ... A nurses note dated 7/13/17 at 7:13 AM documented, Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ... A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed. Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit for inpatient treatment. 8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured. Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, [AGE]-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ... A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list. Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of ...confused, disoriented, found walking through traffic on 440 ... The patient was uninsured. Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalization s, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ... Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, ...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, referred to Call Center/MCRT for disposition... The Emergency Department notes dated 7/16/17 at 11:16 AM documented, Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ... Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ... Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment. 10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured. Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI... Review of the CAPS behavior health assessment dated [DATE] at 4:39 PM revealed the patient was not referred to the psychiatrist on-call. Review of the emergency room Notes dated 10/11/17 at 5:11 PM documented, [Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ... The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation. ED Physician #8 dated 10/13/17 at 5:00 AM documented, ...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ... ED Physician #6's note dated 10/14/17 at 6:28 AM documented, Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ... ED Physician #4's note dated 10/16/17 at 4:09 AM documented, The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ... Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment of Patient #7 or stabilizing treatment for Patient #7's psychiatric condition while the patient remained in Hospital #1's ED for 160 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid). Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, [AGE]-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk... Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, ...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT... ED physician #2 dated 8/25/17 at 5:23 AM documented, Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis. Review of the CAPS assessment dated [DATE] at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate. Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured. Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, ...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged ] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions... Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged ] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen... Further review of the nurse's notes revealed, ...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ... A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the pending board for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list. A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM. Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #10's psychiatric condition while the patient remained in Hospital #1's ED for 99 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid). Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, [AGE]-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ... Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations. A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17. Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM. ED physician #5's note dated 6/2/17 at 6:54 PM documented, Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ... Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance. Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, This is a [AGE]-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are driving him crazy. He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ... Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability. ED physician #6's note dated 6/5/17 at 5:58 AM documented, ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ... A nurse's note dated 6/5/17 at 6:44 PM documented, Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ... A nurse's note dated 6/6/17 at 1:31 PM documented, ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ... Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a psychiatric problem. There was no docu
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff on-Call schedules, medical record reviews and interviews, the facility failed to ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 28 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10,11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26 and 27) patients who presented to the Emergency Department (ED) seeking treatment. The findings included: 1. Review of facility policy, EMTALA - Definitions and General Requirements last reviewed 03/2013, revealed, ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs [Emergency Medical Condition] ... PROCEDURE ...A. General Requirements...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility ... 2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed ...1.B. PURPOSES AND RESPONSIBILITIES...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and... 3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16 revealed, ... EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services: 1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ... 4. Review of Hospital #1's Medical Staff on-call Logs, for the specialty of psychiatry, revealed a Psychiatrist on-call each day for the months of January 2015 through October 2017 when 28 of 31 patients were in the ED. 5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.' The patient was uninsured. Review of the ED notes for Patient #1 revealed on 7/12/17 at 1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ... A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, ...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ... Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, [AGE]-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ... The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation. ED Physician #3's note dated 7/13/17 at 7:32 AM documented, awaiting placement at [name of Hospital #2] ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4. ED Physician #4's note dated 7/15/17 at 12:10 AM documented, This is a [AGE]-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care. ED Physician #5's note dated 7/15/17 at 6:39 AM documented, Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ... ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable. ED Physician #6's note dated 7/16/17 at 5:49 PM documented, Patient has been stable in the emergency department. He was accepted at [named hospital #2] ... Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #1 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #1 was in Hospital #1's ED 100 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, [AGE]-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says I'm really messed up. But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ... The patient had out of state Medicaid insurance. Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ... Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient. Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17. ED physician #4's note dated 7/15/17 at 12:04 AM documented, Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ... ED Physician #5's note dated 7/15/17 at 6:37 AM documented, Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ... ED Physician #7's note dated 7/16/17 at 4:23 PM documented, Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ... ED Physician #6's note dated 7/17/17 at 1:46 AM documented, ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]. Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #2 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #2 was in Hospital #1's ED 105 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter. The patient was uninsured. Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , [AGE]-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ... Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ... The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ... A nurses note dated 7/13/17 at 7:13 AM documented, Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ... A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed. Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #4 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #4 was in Hospital #1's ED 102 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured. Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, [AGE]-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ... A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list. Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #5 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #5 was in Hospital #1's ED 107 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of ...confused, disoriented, found walking through traffic on 440 ... The patient was uninsured. Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalization s, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ... Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, ...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, referred to Call Center/MCRT for disposition... The Emergency Department notes dated 7/16/17 at 11:16 AM documented, Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ... Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ... Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #6 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #6 was in Hospital #1's ED 91 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured. Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI... Review of the CAPS behavior health assessment dated [DATE] at 4:39 PM revealed the patient was not referred to the psychiatrist on-call. Review of the emergency room Notes dated 10/11/17 at 5:11 PM documented, [Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ... The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation. ED Physician #8 dated 10/13/17 at 5:00 AM documented, ...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ... ED Physician #6's note dated 10/14/17 at 6:28 AM documented, Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ... ED Physician #4's note dated 10/16/17 at 4:09 AM documented, The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ... Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #7 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #7 was in Hospital #1's ED 160 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid). Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, [AGE]-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk... Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, ...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT... ED physician #2 dated 8/25/17 at 5:23 AM documented, Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis. Review of the CAPS assessment dated [DATE] at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate. Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #8 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #8 was in Hospital #1's ED 62 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured. Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, ...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged ] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions... Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged ] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen... Further review of the nurse's notes revealed, ...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ... A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the pending board for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list. A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM. Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #10 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #10 was in Hospital #1's ED 99 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid). Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, [AGE]-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ... Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations. A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17. Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM. ED physician #5's note dated 6/2/17 at 6:54 PM documented, Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ... Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #11 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #11 was in Hospital #1's ED 100 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance. Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, This is a [AGE]-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are driving him crazy. He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ... Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability. ED physician #6's note dated 6/5/17 at 5:58 AM documented, ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ... A nurse's note dated 6/5/17 at 6:44 PM documented, Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ... A nurse's note dated 6/6/17 at 1:31 PM documented, ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ... Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a psychiatric problem. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #12 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #12 was in Hospital #1's ED 58 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 15. Medical record review revealed Patient #13 presented to the ED at Hospital #1's campus on 6/7/17 at 7:31 PM via walk-in with complaint of feeling depressed. The patient had stopped taking her psychiatric medications approximately 6 weeks previously, due to being pregnant. The patient was insured (Medicaid). Review of a nurse's note dated 6/7/17 revealed Patient #13 was triaged at 7:38 PM. Further review of the nurse's triage note revealed, ...Pt here with feelings of being depressed, feelings are more intense because she stopped taking her psych meds due to being pregnant. Stopped taking her meds approx [approximately] 6 weeks ago. 17 weeks pregnant ... Review of a nurse's note dated 6/7/17 at 8:35 PM revealed, ...when asked if pt has suicidal thoughts, pt states well I don't think I'll kill myself but I feel like life would be better if I wasn't around ... Medical record review of ED physician #2's note dated 6/7/17 at 8:43 PM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. Review of ED Physician #2's note on 6/7/17 at 8:43 PM revealed, 4-year
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policies, facility bylaws, rules and regulations, facility listing, medical record reviews and interviews, the facility failed to ensure patients with identified emergency psychaitric conditions were transferred to Hospital #1's inpatient psychiatric unit which had the capacity and capability to treat the patients. The hospital failed to minimize the risks to the patients' health by allowing patients with psychaitric conditions to remain in Hospital #1's Emergency Department (ED) for lengthy periods of time without treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat patients with psychaitric conditions resulted in the inappropriate transfer of 19 of 27 (Patient's 1, 2, 4, 5, 6, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 19, 20, 21, 22, 25 and 26) patients who presented to Hospital #1's ED seeking treatment for a psychaitric condition. The findings included: 1. Review of facility policy, EMTALA - Definitions and General Requirements last reviewed 03/2013, revealed, ..To Stabilize means, with respect to an EMC to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility or... Transfer Center means an entity to facilitate the transfer of emergency patients in need of a higher level of care from a transferring facility to an receiving facility via ground or air ambulance transportation. Such Transfer Center provides staffing to facilitate making arrangements for the transfer of such individuals, while the ED physicians or other physicians in there transferring facility retain decision-making responsibilities for determining to which receiving facility the individual is transferred and by what means,...The Transfer Center's main role is to facilitate the transfer between the transferring and receiving hospitals and to be a resource for data on the individual hospitals and their capability and capacity to receive transfer at any point in time...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMSs [Emergency Medical Condition] ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMSs. Only physicians that are available to physically come to the ER may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA ...PROCEDURE: ...A. General Requirements ...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility. 2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed ...1. B. PURPOSES AND RESPONSIBILITIES ...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and ... 3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16, IV. EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services: 1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ... 4. Review of a patient list presented to the surveyors by the Quality Improvement Manager on 12/28/17 at 8:00 AM, revealed the Transfer Center (Call Center) did not refer to (named Hospital #3) for admission. Two patients (Patients #9 and 10) were declined because there was no ADA [American Disabilities Act] room and lack of nursing staff. Twenty-two patients were not referred to the on-site psychiatric hospital (Hospital #3) for treatment. Those patients were: Patients #1, 2, 3, 4, 5, 6, 7, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 19, 21, 22, 25, 26 and 27. 5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.' The patient was uninsured. Review of the ED notes for Patient #1 revealed on 7/12/17 at 1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ... A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, ...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ... Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, [AGE]-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ... The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation. ED Physician #3's note dated 7/13/17 at 7:32 AM documented, awaiting placement at [name of Hospital #2] ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4. ED Physician #4's note dated 7/15/17 at 12:10 AM documented, This is a [AGE]-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care. ED Physician #5's note dated 7/15/17 at 6:39 AM documented, Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ... ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable. ED Physician #6's note dated 7/16/17 at 5:49 PM documented, Patient has been stable in the emergency department. He was accepted at [named hospital #2] ... Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, [AGE]-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says I'm really messed up. But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ... The patient had out of state Medicaid insurance. Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ... Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient. Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17. ED physician #4's note dated 7/15/17 at 12:04 AM documented, Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ... ED Physician #5's note dated 7/15/17 at 6:37 AM documented, Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ... ED Physician #7's note dated 7/16/17 at 4:23 PM documented, Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ... ED Physician #6's note dated 7/17/17 at 1:46 AM documented, ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]. Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility. There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter. The patient was uninsured. Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , [AGE]-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ... Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ... The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ... A nurses note dated 7/13/17 at 7:13 AM documented, Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ... A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed. Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3)for inpatient treatment. 8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured. Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, [AGE]-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ... A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list. Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of ...confused, disoriented, found walking through traffic on 440 ... The patient was uninsured. Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalization s, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ... Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, ...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, referred to Call Center/MCRT for disposition... The Emergency Department notes dated 7/16/17 at 11:16 AM documented, Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ... Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ... Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment. 10. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid). Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, [AGE]-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk... Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, ...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT... ED physician #2 dated 8/25/17 at 5:23 AM documented, Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis. Review of the CAPS assessment dated [DATE] at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate. Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 11. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid). Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, [AGE]-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ... Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations. A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17. Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM. ED physician #5's note dated 6/2/17 at 6:54 PM documented, Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ... Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient was in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 12. Medical record review revealed Patient #13 presented to the ED at Hospital #1's campus on 6/7/17 at 7:31 PM via walk-in with complaint of feeling depressed. The patient had stopped taking her psychiatric medications approximately 6 weeks previously, due to being pregnant. The patient was insured (Medicaid). Review of a nurse's note dated 6/7/17 revealed Patient #13 was triaged at 7:38 PM. Further review of the nurse's triage note revealed, ...Pt here with feelings of being depressed, feelings are more intense because she stopped taking her psych meds due to being pregnant. Stopped taking her meds approx [approximately] 6 weeks ago. 17 weeks pregnant ... Review of a nurse's note dated 6/7/17 at 8:35 PM revealed, ...when asked if pt has suicidal thoughts, pt states well I don't think I'll kill myself but I feel like life would be better if I wasn't around ... Medical record review of ED physician #2's note dated 6/7/17 at 8:43 PM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. Review of ED Physician #2's note on 6/7/17 at 8:43 PM revealed, 4-year old [24] female with long-standing history of bipolar disorder presents saying that she is depressed and feeling worthless. She denies active suicidal or homicidal ideation. She is off all of her medications since she found out she was pregnant...6404 filled out. Awaiting evaluation by mobile crisis... Review of ED physician #16's note dated 6/8/17 at 6:18 AM revealed, Mobile crisis has seen and recommends inpatient. Review of the Emergency Notes on 6/8/17 at 2:44 PM revealed all private facilities had declined patient due to acuity. Hospital #2 was given referral. At 4:13 PM on 6/8/17 the patient was #31 on the waiting list for Hospital #2. Review ED physician #16's note on 6/8/17 at 4:17 PM revealed the patient had been seen by mobile crisis and was waiting for psychiatric placement. Patient #13 was transferred to Hospital #2 on 6/11/17 at 11:20 AM, 87 hours after presenting to the ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #13's psychiatric condition while the patient remained in Hospital #1's ED for 87 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 13. Medical record review revealed Patient #14-1 presented to the ED at Hospital #1's campus on 7/22/16 at 12:15 AM via ambulance with chief complaint of plans to overdose on cocaine, marijuana and alcohol, patient off seizure medications. The patient was uninsured. Medical record review of ED physician #13's note dated 7/22/16 at 12:24 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #13's note dated 7/22/16 at 12:24 AM documented, ...reports he has suicidal thoughts and has a plan to overdose on cocaine, marijuana and drink too much alcohol. Has not been compliant with his medications ... A Certificate of Need for Emergency Involuntary Admission (6404) was completed on 7/22/16 at 12:30 AM. On 7/22/16 at 10:04 AM the ED RN faxed the chart and 6404 to Hospital #2 as requested by Mobile Crisis. Patient was placed as #21 on the waiting list for Hospital #2. Patient 14-2was transferred to Hospital #8 on 7/22/16 at 11:44 PM, 23 hours after presenting to the ED for treatment and stabilization of a psychiatric condition. There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #14-1's psychiatric condition while the patient was in Hospital #1's ED for 23 hours awaiting transfer to an inpatient psychiatric facility. There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment. 14. Medical record review revealed Patient #14-2 presented to the ED at Hospital #1's campus on 10/6/16 at 11:06 PM via ambulance with chief complaint of suicidal ideation. The patient was uninsured. Physician Assistant #4's note dated 10/7/16 at 1:33 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Physician Assistant #4's note revealed the patient reported suicidal ideation today and he has a plan. Review of the Emergency Notes revealed the following: 10/7/16 at 12:36 AM the patient was assessed by CAPS and identified suicidal ideations with alcohol dependency. At 4:24 AM the patients' blood alcohol level was 0.190 which was outside the parameters for Mobile Crisis team. At 9:30 AM, Mobile Crisis evaluated the patient and stated patient could go home and would discuss with ER MD. At 11:20 AM the ED MD stated the patient had to be placed and to let the Transfer Center know for placement. On 10/8/16 at 2:15 AM the patient was moved to a psych safe room in the ED. There was no documentation why the patient was moved. At 3:27 AM per the Transfer Center, the patient was to receive Telemedicine because he had been denied everywhere. Telemedicine Physician #1's Psychiatric Evaluation Note from the Telemedicine referral dated 10/8/16 at 4:21 AM documented, ...Risk factors: Homeless, lack of engagement in outpatient treatment, lack of primary support, history of prior suicide attempts, recent use of cocaine, ETOH [alcohol]. Plan: Based on above mentioned risk factors and on patient being unable to contract for safety on assessment today, it is recommended that patient be transferred to an inpatient facility for treatment of mood disorder and stabilization before being referred to a treatment facility for rehab ... Patient #14-2 was discharged to Hospital #2 on 10/8/16 at 12:24 AM for further evaluation of a psychiatric condition. There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #14-2 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #14-2 was in Hospital #1's ED 46 hours awaiting placement/transfer to an inpatient psychiatric treatment facility. 15. Medical record review revealed Patient #14-3 presented to the ED at Hospital #1's campus on 10/28/16/16 at 11:58 PM via ambulance with chief complaint of drunk and suicidal. The patient was uninsured. Medical record review of ED physician's assistant (PA) #4's note dated 10/29/16 at 12:24 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED PA #4's note dated 10/29/16 at 12:24 AM documented, ...C
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Intakes: TN 858 Based on policy review, medical record review, observation and interview, the hospital failed to ensure nursing care assessments were conducted to identify the needs of 3 of 3 (Patient #1, 2 and 3) sampled patients. The findings included: 1. Review of the facility's Assessment/Reassessment/Plan of Care of Patients policy revealed, ...Patients at the facility receiving...Emergency Department (ED) services will have an initial assessment and appropriate follow-up assessments based upon their individual needs...The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible. The goals of the care planning process are to identify and prioritize care and treatment...All assessments provided by health care professionals will be based on and include...Data collected to assess the needs of the patient...Assessments/Reassessment Matrix...Area...Emergency Department Level 3: Urgent...Initial Admission Assessment & [and] Care Plannng [Planning] Completion Time Frame...Primary RN = < 30 minutes...Reassessment & Care Planning Time Frame...2-4 hours as condition warrants...Initial Assessment/Screening...The assessment process will be collaborative to facilitate, identify, and prioritize the patient's needs and determine care...The design, by health care providers of a discipline specific assessment includes but is not limited to the following...Pain management...Reassessment is focused toward the problem areas identified through the initial assessment...Care planning is focused toward the problem areas identified through the initial assessment and subsequent reassessments, and any new problems or complaints noted by the patient, family or caregivers... Review of the facility's Pain Assessment and Reassessment, Management and Documentation policy revealed, ...[named hospital] assesses, reassesses and manages its patients' pain consistent with scope of care, treatment, services and the patient's condition...Reassessment of pain after the administration of pain medication is dependent on several patient factors (age and disease process) and medication factors (drug, dose, route, absorption, onset, peak, etc (et cetera; and so forth))...the goal is to assess the effectiveness of pain medication within one hour of administration ...Pain Assessment (includes the following)...Frequency...Pain descriptors and indicators...Patient teaching...Documentation... 2. Medical record review for Patient #1 revealed an arrival date to the ED on 3/8/17 at 8:39 PM with chief complaints of non-productive cough, generalized myalgia, headache, fever, and chills for 3 days. Patient #1 was admitted to the hospital with the diagnosis of [DIAGNOSES REDACTED]EMERGENCY PATIENT RECORD dated 3/8/17 revealed, ...Priority: 3 [Emergency Severity Index (ESI)]...03/08/17...2045 [8:45 PM]...PT [patient] C/O [complained of] 9/10 [9 on a 1 to 10 scale] GENERALIZED PAIN...]...[signed by Nurse #1]...03/08/17 2225 [10:25 PM]...Pain intensity: 10...[signed by Nurse #2]... The MEDICATION DISCHARGE SUMMARY dated 3/8/17 to 3/9/17 revealed, ...TYLENOL EXTRA STRENGTH 1,000 MG [milligrams] PO [by mouth] X [times] 1...03/09/17...0038 [12:38 AM]...GAVE: 1,000 MG...Pain intensity...9...[signed by Nurse #2]...REASSESS...[no reassessment documented]...KETOROLAC TROMETHAMINE [Toradol]...30 MG IV [intravenous] X 1...03/09/17...0052 [12:52 AM]...GAVE: 30 MG...Pain intensity: 8...[signed by Nurse #2]...REASSESS...[no reassessment documented]... There was no reassessment of Patient #1's pain after the Tylenol and Ketorolac were administered. The next documented pain assessment was on 3/9/17 at 4:24 AM with a pain rating of 0 on a 1-10 scale (3 hours 32 minutes after the last pain medication had been administered). The EMERGENCY PATIENT RECORD revealed, ...03/08/17 2040 [8:40 PM]...Temperature F [Fahrenheit]: 101.7...03/09/17 1039 [10:39 AM]...Temperature F: 103.7... There was no temperature documented from 8:40 PM on 3/8/17 to 10:39 AM on 3/9/17 (13 hours 59 minutes]. 3. Medical record review for Patient #2 revealed an arrival date to the ED on 1/10/17 at 12:43 PM with a chief complaint of headache. Patient #2 was admitted to the hospital with diagnoses of [DIAGNOSES REDACTED] dated 1/10/17 revealed, ...Arrival Date/Time: 01/10/17 - 1243 [12:43 PM]...Triage Date/Time...01/10/17 - 1309 [1:09 PM]...Priority: 3 [ESI]...PT [patient] COMPLAINING OF A HEADACHE AND DIZZINESS SINCE AN EPIDURAL ON THURSDAY [5 days prior]...[signed by Nurse #3]... There was no pain assessment documented in the triage assessment. The EMERGENCY PATIENT RECORD revealed, ...01/10/17...1441 [2:41 PM]...Pain intensity: 10... The MEDICATION DISCHARGE SUMMARY revealed, ...DILAUDID...1 MG IV X 1...01/10/17...1458 [2:58 PM]...GAVE: 1 MG...Pain intensity: 10...[signed by Nurse #4]...REASSESS...[no reassessment documented]... There was no reassessment of Patient #2's pain after the Dilaudid was administered. The next documented pain assessment was on 1/11/17 at 3:52 AM with a pain rating of 10 on a 1-10 scale (12 hours 54 minutes after the pain medication had been administered). During Patient #2's stay in the ED (on 1/10/17 from 12:43 PM to 7:00 PM (6 hours 17 minutes) there was only two documented pain assessments (at 2:41 PM and at 2:48 PM)). 4. Medical record review for Patient #3 revealed an arrival date to the ED on 3/6/17 at 10:32 AM with chief complaints of Diarrhea, Gastrointestinal (GI)/Abdominal Pain, and Body Cramps. Patient #3 was admitted to the hospital with diagnoses of [DIAGNOSES REDACTED]EMERGENCY PATIENT RECORD revealed, ...Arrival Date/Time: 03/06/17 - 1032 [10:32 AM]...Triage Date/Time: 03/06/17 - 1040 [10:40 AM]...Priority: 3 [ESI]...PT STS [states] SHE HAD AN ILEOSTOMY SURGERY THREE WEEKS AGO AND HAS BEEN HAVING TROUBLE RETAINING FLUID...THIS MORNING STARTED HAVING DIARRHEA AND BODY CRAMPS...Chief Complaint: GI/Abdominal Pain...[signed by Nurse #3]... There was no pain assessment documented in the triage assessment. The MEDICATION DISCHARGE SUMMARY revealed, ...DILAUDID...1 MG IV X 1...03/06/17...1148 [11:48 AM]...GAVE: 1 MG...Pain intensity: 8 [first documented pain assessment: 1 hour 16 minutes after arrival and 1 hour 8 minutes after triage]...[signed by Nurse #5]... The EMERGENCY PATIENT RECORD revealed, ...03/06/17 1300 [1:00 PM]...Pain intensity: 7...[signed by Nurse #5]... The MEDICATION DISCHARGE SUMMARY revealed, ...DILAUDID...1 MG IV X 1...03/06/17...1650 [4:50 PM]...GAVE: 1 MG...Pain intensity: 9... There was no pain assessment documented from 1:00 PM to 4:50 PM (3 hours 50 minutes) on 3/6/17 after Patient #3 rated pain as a 7 on a 1-10 scale. 5. During an interview in the conference room on 3/21/17 at 7:52 AM, Nurse #2 stated nurses were to check vital signs and conduct pain assessments every hour in the ED. Nurse #6 stated when ED patients were admitted but still remained in the ED, nurses were to check vital signs and conduct pain assessments every 4 hours. During an interview in the conference room on 3/21/17 at 8:02 AM, the ED Director stated nurses were supposed to conduct a pain assessment during triage and reassess pain within at least an hour after administering pain medication. During an interview in the conference room on 3/21/17 at 10:30 AM, the ED Clinical Educator stated nurses should reassess patients in the ED every hour including pain assessment and full vital signs. The ED Clinical Educator stated nurses should conduct an initial pain assessment in triage, another pain assessment when the patient was brought back to a room and then another 30 minutes after the patient had arrived in the room. The ED Clinical Educator stated nurses should get all five vital signs (temperature, respiratory rate, pulse, blood pressure and oxygen saturation) at triage and every hour for any sign which is abnormal.
Based on policy review, facility document review, review of the hospital's Emergency Department (ED) Central Log, medical record review and interview, the hospital failed to ensure each patient who presented on the ED Central Log and received an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed. The findings included: 1. The hospital failed to ensure each patient who presented on the hospital's ED Central Log, at the time they presented for 1 of 20 (Patient #1) sampled patients. Refer to 2405 2. The hospital failed to ensure all patients presenting to the ED seeking treatment received an appropriate MSE to determine if an emergency medical condition existed for 1 of 20 (Patient #1) sampled patients. Refer to 2506
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, facility document review, review of the hospital's Emergency Department (ED) Central Log and interview, the hospital failed to ensure each patient who presented on the hospital's ED Central Log at the time they presented for 1 of 20 (Patient #1) sampled patients. The findings included: 1. Review of the policy EMTALA [Emergency Medical Treatment and Labor Act] -Tennessee Central Log Policy revealed, ...The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination ('MSE') could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted treated, stabilized and transferred or discharged ... 2. Review of the facility investigation which included an internal email dated 8/6/16 from RN #2 to the ED Director revealed, ...I received a call from [family member of Patient #1] Saturday around 11:30 regarding her niece [Patient #1]. She says she [Patient #1] was seen here Monday August 2nd and discharged with a dx [diagnosis] of kidney stones....She claims she came back Tuesday and was never taken back to a room, given something in the waiting room and told to go home. She says she is now in renal failure and is going to have multiple surgeries...There is nothing in the computer for August 3rd... 3. The ED Central Log dated 8/3/16 documented Patient #1 presented to the ED, refused treatment and left against medical advice prior to MSE. 4. During an interview in the conference room on 9/12/16 at 11:50 AM, the ED Manager was asked if Patient #1 was documented on the Central Log. She stated Patient #1 was not on the Central Log when she initially pulled it for review. She further stated, ...Once it was determined a possible EMTALA violation, we were instructed by Ethics to add the patient to the log... She again verified Patient #1 was not documented in the log at the time she (MDS) dated [DATE].
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, facility document review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED)seeking treatment, received an appropriate medical screening exam (MSE), according to hospital policy to determine if an emergency medical condition existed for 1 of 20 (Patient #1) sampled patients. The findings included 1. Review of the policy EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination Stabilization, revealed, ...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition...Further, if a prudent layperson observer would believe that the individual is experiencing and EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA...An MSE is required when: a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition... 2. Medical record review for Patient #1 documented the patient presented to the ED at Hospital #1 via private vehicle on 8/2/16 at 5:29 AM with complaints of kidney stones and was triaged at 5:29 AM ED Physician #1 documented the MSE was initiated at 5:30 AM and the patient complained of flank pain with sudden onset. He further documented, Onset 2 AM with left flank pain similar to past kidney stones...Vomited just prior to me going into room. Patient #1 reported back pain, lumbar pain and a history of kidney stones. Nursing notes at 540 AM revealed left flank pain rated 9 . Laboratory results for Patient #1 revealed the following: Glomerular Filtration Rate- greater than 90 and elevated Neutraphils- 70.6. Urinalysis results revealed: urine positive for blood, urine positive for nitrates, and urine with elevated red blood cells (54), elevated white blood cells (16) and elevated Leukocyte Esterase (trace). Computerized Tomography of the abdomen and pelvis results documented, Impression : 4 X [by] 3 mm [millimeter] proximal LEFT ureteral stone with mild LEFT [DIAGNOSES REDACTED]. The patient received the following medications intravenously: Sodium Chloride, Hydromorphine Hydrochloride, Ketorolac tromethamine, Ondansetron Hydrochloride. At 6:37 AM, the nurse documented the patient was pain free. The patient was discharged home at 7:15 AM in stable condition with a diagnosis of [DIAGNOSES REDACTED]. Rest ...push fluids ...follow up with your Urologist tomorrow for recheck ...take meds as directed ...return for fever chills dizzy or passing blood in stool or increased pain ...prescriptions written: Percocet 5 milligrams [mg]/325 mg take 1-2 tablets by mouth every 4-6 hours as needed for pain ...Zofran 4 mg...let 1 tablet dissolve in mouth every 8 hours as needed for nausea, vomiting ...Levaquin 750 mg take 1 tablet by mouth each day ...Finish All of This Medication ... 3. Review of the facility investigation which included an internal email dated 8/6/16 from Registered Nurse [RN] #2 to the ED Director revealed, ...I received a call from [family member of Patient #1] Saturday around 11:30 regarding her niece [Patient #1]. She says she [Patient #1] was seen here Monday August 2nd and discharged with a dx [diagnosis] of kidney stones....She claims she came back Tuesday and was never taken back to a room, given something in the waiting room and told to go home. She says she is now in renal failure and is going to have multiple surgeries...There is nothing in the computer for August 3rd... 4. Review of 'Patient Notes for Patient #1 dated 8/3/16 revealed Nurse #1 documented, PT [Patient #1] CAME TO THE ER STATING THE PERCOCET MADE HER SICK. [ED Physician #2] ORDERED TORADOL 10 MG PO [by mouth] FOR PAIN PRN [as needed] QUANTITY 20. RX [prescription] CALLED TO [name of pharmacy]. Patient #1 was not added to the Central Log, was not triaged and did not receive a MSE. 5. On 8/4/16 at 3:46 PM Patient #1 was admitted to Hospital #2. Review of discharge summary documentation by the Hospitalist revealed Patient #1 was admitted with presenting diagnoses of [DIAGNOSES REDACTED] yesterday 8/3/16 she had returned to the ED at Hospital #1 after she developed fever/chills ...Today 8/4/16 the abdominal and flank pain increased and she presented to the ED for further evaluation. Urology was consulted and she was taken to surgery for a cystoscopy and stent placement. I&O [intake and output] from PACU [post anesthesia care unit] includes 1200 ml [milliliter] crystalloid, UOP [urinary output] 500 ml, EBL [estimated blood loss] <5 ml. She was marginally hypotensive in the PACU and transferred to critical care. Further review revealed Patient #1 was admitted to the ICU for pyelonephritis with sepsis and Left ureteral stone, postoperative diagnoses of [DIAGNOSES REDACTED]#1 was discharged home on 8/7/16. 6. During a telephone interview on 9/13/16 at 1:27 PM, Patient #1 was asked about her visit to the hospital ED on 8/2/16. She stated she went to the hospital ED in pain and she felt it was a kidney stone because she had a history of kidney stones. She stated she was given medications and according to an X-ray she had a kidney stone that the physician advised she would pass in 24 to 36 hours. She stated the next day (8/3/16) she wassick and in a lot more pain. Patient #1 stated that her grandmother called the ED on 8/3/16 and asked to have her medicine changed, because they thought the pain medicine was making her sick. Patient #1 stated her grandmother was told Patient #1 would have to come back to the ED to be seen again She stated she had a fever but she had to wait later in the day for someone to transport her to the ED because she had been taking pain medication. Patient #1 stated when she (MDS) dated [DATE] the registrar at the front desk was very rude. Patient #1 stated she told the registrar she was sick and needed a different pain medication. Patient #1 stated the registrar told her, There is nothing we can do for you, your doctor is not here... Patient #1 stated at that point RN #1 opened the door and said 'I remember her, I discharged her'... Patient #1 stated, I told them I needed to be seen Patient #1 stated she had just vomited in the waiting room bathroom and she was holding a green emesis bag when the nurse approached her in the waiting room. Patient #1 stated RN #1 went back to talk to the ED physician, came back out to the waiting room and told her they would change her pain medication. Patient #1 stated the medication Toradol was called in to her pharmacy and she picked it up the same day. Patient #1 stated that the following day 8/4/16, her grandmother called to get her an appointment with a Urologist. She stated when she arrived at the Urologist office, they obtained a urine sample and her temperature was 102.5. She stated she was very sick, in a lot of pain, had fever and even blurred vision She stated the Urologist said she would need emergency surgery because she was septic and he was sending her to Hospital #2 for admission. During a telephone interview on 9/13/16 at 9:13 AM, RN #1 was asked about Patient #1's visit to the ED on 8/3/16. She stated, ...I heard Patient #1 ask Registrar #1 if she would have to make another co-pay. She stated she looked up and recognized Patient #1 because she had discharged her and she recalled she had a kidney stone. RN #1 stated, I walked out into the lobby and said What's going on...She [Patient #1] said medicine is making me sick RN #1 stated she asked Patient #1 which medicine was making her sick. Patient #1 replied the pain medication was making her sick. RN #1 stated she told Patient #1, I know you have a history of kidney stones...I know you have taken Toradol, would Toradol work for you? RN #1 stated she told Patient #1 she would need to go back and talk with the ED Physician [ED Physician #2]. RN #1 stated she walked back into the ED, explained to ED Physician #2 that Patient #1 was treated earlier this morning for kidney stones. RN #1 stated ED Physician #2 stated he was not prescribing any narcotics. RN #1 then asked ED Physician #2 if he would prescribe Toradol for Patient #1. RN #1 stated ED Physician #2 agreed to prescribe Toradol. When asked if ED Physician #2 was aware Patient #1 was physically present on the hospital premises, RN #1 stated, I told [named ED Physician #2] she was in the lobby. She stated, I didn't think I did anything wrong...she [Patient #1] didn't look sick, she looked good. When asked if it was common practice for patient's treated in the ED to call back for a medication change, RN #1 stated, If you called back tomorrow, I might say what medication...Yes mam' we would do it...others have done it...put patient on hold, look at history, allergies and talk to physician... During an interview in the conference room on 9/13/16 at 11:12 AM, ED Physician #2 was asked what he recalled about 8/3/16, the date Patient #1 presented to the ED. He stated, What I recall... very busy that day...usually I hear [everything around me] but so busy ...I didn't. When asked what RN #1 told him about Patient #1 he stated, seen for kidney stones yesterday, can I call in medication... He stated he told RN #1 he could not call in any narcotics. He stated he agreed to call in Toradol. When asked if it was common practice to change or call in medications for a patient previously treated in the ED, even by another ED physician, ED Physician #2 stated, It's not uncommon, if it's not a controlled substance...yes we would change the medication. ED Physician #2 stated he thought Patient #1 called on the telephone. He stated he was not aware she was in the ED. He stated, If I would have known she was here...would have patient check in so we could re-evaluate [the] patient. During an interview on 9/13/16 at 3:40 PM, the ED Manager was asked what her expectation was when a patient presented to the hospital ED. She stated, ...we assume all are seeking to see the doctor for an emergency medical condition... A telephone interview was attempted with Registrar #1 on 9/13/16 at 1:53 PM and on 9/14/16 1:49 PM, with no success. The hospital submitted documentation indicating that they had reviewed the circumstances and had put corrective actions in place. Additionally, they reported the incident to the Regional Office. The administration has taken immediate measures to ensure this type of incident will not occur in the future. The following corective action has been or will be taken: On 08/10/16, the Registrar and ED RN involved in the incident were immediately suspended pending final resolution of the review. On 08/10/2016, the Ethics and Compliance Officer (ECO), Chief Nursing Officer and Spring Hill ED Director discussed the incident with ED Physician-2 and explained the importance of verifying whether a patient is present in the ED if medical/medication questions are asked by ED staff, even if that means questioning the ED staff member further before providing guidance. ED Physician-2 agreed that if such questions were asked about a patient who was present in the ED, the patient should receive a medical screening examination prior to providing any medical advice or medication changes. ED Physician-2 indicated that if he would have known that the Patient was in the ED, he would have ensured the Patient received an MSE. On 08/12/2016, the ED RN's employment was terminated. On 08/16/2016, the ECO, Patient Access/Registration ED Manager, Patient Access/REgistration Interim Centennial Director and Spring Hill ED Director held a department meeting with all Spring Hill ED and registration staff. Leadership discussed the incident, explained how the situation should have been handled and provided EMTALA education. During the department meeting on 08/16/16, registration staff were assigned the online EMTALA Power Point. The Patient Access director will ensure that all registration staff will receive education on a quarterly basis. All registration staff have been assigned the EMTALA Health Stream educational course with a completion date of 08/31/2016. The Registrar was assigned the EMTALA Health Stream educational course for registrars with a completion date of 09/15/2016. ++++++++++++++++++++++++Review and verification of training documentation and interviews revealed corrective actions initiated included Web-based EMTALA training, beginning 8/16/16, as well as attendance of a live EMTALA training presentation 8/16/16 for employees. The employees unable to attend the live presentation, viewed a recorded version of the EMTALA presentation which was made available after the 8/16/16. Further review and verification of training documentation and interviews revealed corrective actions also initiated included the following trainings: Reportable Issues Case Studies/Test training 8/16/16, Prescription Medication Practice information initiated 8/11/16 and training related to whether a patient is/not placed on the Central Log was initiated 9/7/1916. The facility completed a late entry in the ED Central Log, as well as a note documenting the patient presented for treatment 8/3/16 but was not seen. The contracted Clerk/Registar involved in this incident was given additional training by the contract company with which she is employed. The contracted Clerk/Registrar involved in this incident was replaced by a different Clerk/Registrar.
Intakes: TN 723 Based on policy review, grievance log review and interview, the hospital failed to follow its policy for resolution of grievances for 1 of 3 (Patient #3) sampled patients. The findings included: 1. A facility policy titled, Patient Grievance and Complaint Management Policy documented, ... Patient grievance is a written or verbal complaint... A grievance/complaint log will be maintained... The documentation in the log will include date of complaint, location, summary of issue, how the issue was addressed, date resolved and response to complaint, and the individual responding to the grievance... 2. The facility grievance log was reviewed. There was no documentation regarding a complaint verbalized to the Chief Nursing Officer (CNO) by Patient #3 in October 2015. 3. During an interview with the Chief Nursing Officer (CNO) on 12/21/15 at 2:30 PM in the conference room, the CNO stated, ...She (Patient #3) came to the hospital to talk to me... I told her I would investigate... I couldn't verify anything by looking in her chart... or interviewing staff... I just couldn't substantiate anything... I called and told her our findings... I didn't put it in the book... that's all on me... I should have...
Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #1) sampled patients who was refused care by Hospital #1. Refer to findings in deficiency A2406
Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #1) sampled patients who was refused care by Hospital #1. The findings included: 1. Review of Hospital #1's policy, EMTALA - DEFINITIONS AND GENERAL REQUIREMENTS, revealed, ...POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who comes to the emergency department an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists, regardless of the individual's ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care on hospital property, other than a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made... 2. Review of the ED Log for Hospital #1 dated 7/26/14 revealed patient #1 arrived at 5:15 PM. The entry documented the reason for the visit, THOUGHT SHE SWALLOWED A THUMB TACK. The disposition category documented, Was refused Treatment. 3. Review of 9 medical records from Hospital #1 for Pt #1 revealed diagnoses of Bipolar Disorder, PICA [an abnormal craving or appetite for nonfood substances], Impulse Control Disorder, Chronic Constipation and Borderline Personality Disorder. The records revealed ED visits on 3/3/14, 5/6/14, 5/10/14, 5/17/14, 5/21/14, 7/14/14, 8/3/14, 8/9/14, and 8/19/14. Seven of the visits were for swallowing metal objects, one was for abdominal pain and one was for swallowing an unknown object. Review of a Patient Notes document dated 7/29/14 at 8:53AM for Pt. #1 revealed the ED Director documented, 7/28/14 at 12:05pm Attempted to call patient to check on her and see how she was doing. No answer. 7/28/14 at 17:28 [5:28] pm Attempted to call patient again. No answer. 7/29/14 at 8:36 am. Called and spoke with patient. She states she is doing well. She did seek treatment at another facility. I apologized to her for the misunderstanding that occurred on Saturday upon her arrival at our facility. I further explained to her that she was always welcome to come to our facility for any type of medical treatment. Patient thanked me for calling and verbalized understanding. There was no further medical record documentation of this visit for Pt. #1. 4. Review of a medical record from Hospital #2 for Pt. #1 dated 7/26/14 revealed the pt. arrived at this hospital ED at 6:07 PM. The reason for the visit was the pt. had swallowed an unknown object, possibly a thumb tack. Radiologic examinations did not identify any foreign body and the pt. was discharged home the same day with discharge instructions to return for problems, concerns or pain and to watch her stool for any foreign body. 5. During an interview in the ED physician's office on 8/25/14 at 10:40 AM, the ED Director for Hospital #1 stated she was notified on 7/27/14 that Pt #1 had been refused treatment without a MSE being performed. Security Officer #1 had recognized the patient from a previous incident in March, 2014 and told the staff the patient could not come back on the property unless it was an emergency. She stated the patient was put on the ED log as a late entry with a note that the patient was refused treatment. On 7/28/14 the ED Director had attempted to reach the patient twice via telephone with no answer. On 7/29/14 the ED Director had spoken with with patient. 6. During an interview in the ED physician's office on 8/26/14 at 2:17 PM, Registered Nurse (RN) #1 for hospital #1 stated she was working triage on 7/26/14 when Pt #1 came into the ED. She stated the patient was in no distress and had been at the snack machine located in the ED waiting room. She stated she was told by Security Officer #1 that the patient had a no trespass warrant against her and could not come on the property. 7. During an interview on 8/26/14 at 2:45 PM, RN #2 for Hospital #1 stated she did not see Patient #1 come to the ED attempting to get medical care. She was caring for other patients. RN #2 stated she heard other staff talking about a patient who was denied treatment. RN #2 stated the security officer said Patient #1 had a trespassing warrant against her and could not come on the property. RN #2 stated to another RN that she was pretty sure we have to screen her... The other nurse stated if the patient presented to the ED by ambulance then they had to screen her. RN #2 stated she did not agree with the other nurse. RN #2 stated she did not know until after the incident Patient #1 was the patient that had been denied treatment. 8. During a telephone interview on 8/26/14 at 3:00 PM, RN #3 for Hospital #1 reported the following to the surveyors: She was working 7/26/14 when Patient #1 came to ED. The security officer told Patient #1 she had a trespassing warrant and was not supposed to be seen in the facility. The security officer said the patient was not supposed to be on the property unless it was an emergency. RN #3 stated the security officer printed some type of paper from the computer and gave it to the patient's caregivers. The patient and the caregivers left. RN #3 stated when she arrived at ED #1 the next morning, she and some of the other staff talked about the incident. RN #3 stated she had thought about the incident, and she notified her immediate supervisor. RN #3 stated at the time of the incident on 7/26/14 she did not think anything about the patient being asked to leave. She stated it, sounded so legal... so lawful... that's what threw me... 9. During a telephone interview on 8/26/14 at 4:00 PM, ED Clerk #1 stated, I was working and [stated Pt #1's name] came to the ER [emergency room ] and stated she had swallowed some tacks. I was pulled towards the nurses station and told by the security guard [Security Officer #1] and charge nurse [RN #1] that we could not treat her... We were given a piece of paper that said she [Pt #1] could not come on the premises unless in an ambulance. The caregivers [for Pt. #1] were not aware of this either ...I did not read the paper... he [Security Officer #1] said the paper said she could not come here unless in an ambulance... 10. During an interview in the physician's office on 8/27/14 at 8:30 AM, Security Officer #1 revealed he had worked as an armed security officer with hospitals for 7+ years. He stated in March 2014, Pt #1 came to the ED, received treatment and was discharged . The patient went to the waiting room and was there for about 15-20 minutes, he could hear voices getting louder and that she liked attention. He went to the waiting room and asked her to leave. He tried coaxing her to leave. After 5-10 minutes, she was not budging. She began to get louder and started kicking at the staff. Security Officer #1 stated, I thought I could bluff her, it didn't work... called police... They came and talked to her for 10-15 minutes too. Even after they told her they would cuff her, she refused to leave. They told her she was under arrest and she left with them. I did not see her again after March until this incident. I was sitting at the desk when I heard her come in and she was giggly and I heard her tell the Registrar, 'I think I swallowed a thumb tack' I printed a copy of my report [incident report] that said she was trespassed from the property. He explained that a trespass warrant is an agreement between the patient, himself [Security Officer] and an officer of the [named the local police department] that agree the patient has trespassed and can't come back on the property. He stated he gave the patient's caregivers a copy of the incident report and they apologized and left with the patient... 11. During an interview in the physician's office on 8/25/14 at 1:55 PM, the Director of the ED for Hospital #1 stated RN #1 notified her of the event on the morning of 7/27/14. She stated RN #1 told her a patient was denied treatment on 7/26/14. The Director of the ED stated she reported the incident to her supervisor. She stated the facility had training for all staff after 7/26/14 and after speaking with staff, she felt the staff at the facility knew what EMTALA was, but when the trespass warrant was thrown into the mix, it was confusing for everyone. Review and verification of training documentation and interviews revealed corrective actions initiated included Security Officer #1 completed a web-based EMTALA training on 7/29/14 and a live presentation on 7/30/14. The three RN ' s involved completed web-based EMTALA training and live training. The remaining ED staff received live EMTALA training on 8/1/14. Annual refresher courses will now be required for all security, ED and labor & Delivery staff. New hire orientation for Security and ED employees has been revised to include EMTALA regulations. Additionally, the facility indicated in writing that it completed the following corrective actions: 1. Completed a late entry in the ED Central Log noting the patient was refused treatment on 07/26/14. 2. On 07/29/14, the Security Officer completed an EMTALA training course in HealthStream, a web based training module. 3. On 07/30/14, the Security Officer also attended an EMTALA training presentation presented by the Centennial Ethics and Compliance Officer. 4. The three RN's who witnessed the incident completed the EMTALA training course in HealthStream. They also attended and participated in the EMTALA training presentation by the Ethics and Compliance Officer on 07/30/2014. 5. On 08/01/2014, the Ethics and Compliance Officer presented EMTALA training to the remaining Spring Hill ED staff members. 6. All Security staff members at the two other campuses, Centennial Medical Center and Centennial Medical Center-Ashland City, completed the HealthStream EMTALA training course by 08/08/14. 7. The Ethics and Compliance Officer will present an EMTALA training presentation to the ED staff members at the other two campuses by 08/29/14. 8. Annual EMTALA Refresher course will be required for all ED, Security and Labor and Delivery staff members. 9. Centennial's New Hire Orientation for ED and Security staff members has been revised to include a review of EMTALA regulations.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Intakes: TN 063 Based on policy review, medical record review and interview, it was determined the facility failed to ensure the nutritional needs of 1 of 5 (Patient #3) sampled patients were met. The findings included: 1. Review of the facility's NUTRITIONAL ASSESSMENT BY METABOLIC SUPPORT SERVICE policy revealed, ...PURPOSE: To provide guidelines for evaluation of the patient's nutritional status prior to the initiation of appropriate nutritional support and to provide information as to the effectiveness of nutritional therapy...Indications for Nutritional Support...Nutritional support should be instituted to prevent the development of protein-calorie malnutirition or as soon as the diagnosis is made...Protein-calorie malnutrition should be suspected and nutritional support provided when any of the following are present...Somatic wasting, e.g. [for example]; pressure sores or a cachetic state... 2. Medical record review for Patient #3 revealed an admission date of [DATE] with diagnoses of Alzheimer's Disease, Suicidal Ideation, Dementia in Conditions with Behavioral Disturbances, Psychosis, Hypertension, Vitamin D Deficiency, Esophageal Reflux, Osteoporosis, Hypopotassemia, and Iron Deficient Anemia. The Sign-in Sheet for Emergency Services dated 12/20/12 documented, ...CURRENT SYMPTOMS...Unexplained weight loss [circled]... The PSYCH [psychiatric] ADMISSION ASSESSMENT dated 12/21/12 documented, ...General appearance...SLENDER...UNDERNOURISHED... The NUTRITION INITIAL SCREEN/ASMNT [assessment] dated 12/21/12 documented, ...Nutrition Plan: NOTIFY RD [Registered Dietician] IF RISK CHG [change]...MONITOR NUTRITION STATUS... The PSY [psychiatric]: TREATMENT PLAN - REVIEW dated 12/21/12 documented, ...PROBLEM: Nutritional Status, Altered... The PATIENT CARE INQUIRY dated 1/9/13 documented, ...Dec [December] 21, 12...Wt [weight] - Lbs [pounds]...116...Jan [January] 03, 13...Wt - Lbs...107...[DATE]...Wt - Lbs...106... The NUTRITION FOLLOW UP/RE-ASSESS dated 1/3/13 documented, ...Weight Changes...107.5 lbs. (Observed 1/3)...Nutrition Comment: Coontinue [continue] to monitor wt. and intake... Patient #3 had a 8.5 pound weight loss (7.3%) from 12/21/12 to 1/3/13. The patient was reassessed, but no new interventions were put in place. The patient continued to lose weight from 1/3/13-1/6/13 with a 1.5 pound weight loss (total of 8.6% weight loss from 12/21/12-1/6/13) without any new interventions put in place. 3. During an interview in the conference room on 3/4/13 at 3:30 PM, when asked how the facility addresses a patient's nutritional status, the Vice-President of Quality/Risk Management stated, ...wieghts are done by the techs [technicians]...on Sunday...[staff] chart on each meal...ask families for preferences...[Registered Dietician] looks at weight on the computer... When asked how the Registered Dietician documents interventions to prevent a patient's weight loss, the Vice-President of Quality/Risk Management stated, ...generally she writes a note... 4. During a telephone interview on 3/7/13 at 12:40 PM, the Vice-President of Quality/Risk Management confirmed no new interventions were put in place to prevent further weight loss for Patient #3. 5. During a telephone interview on 3/7/13 at 12:43 PM, when asked about Patient #3's weight loss, Nurse #1 stated she believed Patient #3's 12/21/12 recorded weight to be a stated weight. When asked what the facility's policy was for admission weights, Nurse #1 stated, ...we are supposed to wiegh them [patients]... When asked if the 12/21/12 recorded weight was documented as being a stated weight, Nurse #1 stated, no.
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