University Medical Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43999 Based on medical record review, policy review, and staff interview, the hospital staff failed to supervise and evaluate nursing personnel and adhere to hospital policy for 5 out of 10 patients (#1,10, 11,16 & 17) admitted to 5 West Unit. Findings: Review of policy, “Nursing Assessment for Observation of Patients on 5 West OBS partly stated: “...IV. Evaluation A. Ongoing re-evaluation and assessments will be completed throughout the duration of the patient’s stay in the OBS Unit. B. The patient’s response to interventions ordered by the primary or provider will be documented in the EMR. “ Patient #1 medical record revealed: - On 3/15/24 at 1059, pt #1 transferred to 5 West OBS floor from Post Anesthesia Care Unit: (PACU) - Physician orders : SCD (sequential compression device) - Patient was discharged home on 3/17/24 at 1457. - No documentation for ordered SCDs were implemented throughout hospitalization. Review of the charts for patients 10, 11, 16, & 17 revealed no documentation of ordered SCDs being implemented. An interview on 10/15/24 conducted with staff #6 and staff # 10 confirmed there was no documentation of implementation of the physician ordered SCDs and the nurses did not follow the hospital policy.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 47578 Based on record review and interview, the facility failed to maintain a medical record which documented all orders for 1 of 20 patients (Patient #1) to include patient evaluations, treatment, and discharge planning. Patient #1 was discharged without a follow up psychiatric assessment and discharge orders in the patient’s medical record. The findings were as follows: Record Review Patient #1’s medical record, dated 4/1/2024, revealed: Patient #1 presented on 4/1/2024 at 4:37 PM seeking treatment for back pain and suicidal ideation with a plan. The patient admitted to having a firearm and medications at home which could be used to achieve their desired outcome. The patient was provided with a psychiatric assessment which revealed that the patient was “an increased risk to themselves and others.” The patient voluntarily agreed to be transferred for inpatient psychiatric treatment due to the facility not having psychiatric services. The patient was provided with a sitter while awaiting transport to the inpatient facility and received a vital check every hour. The inpatient facility arranged for the patient was two hours away therefore the facility encountered issues finding transportation. When the nurse returned to round on the patient’s vitals, the patient became agitated and indicated they wanted to leave. The nurse removed the patient’s IV, had them sign an AMA (against medical advice) form, and allowed the patient to leave. The patient is then documented back at the facility within 23 minutes and remains at the facility for 7 more hours before being discharged on 4/2/2024 at 7:44 AM. There are no notes in the medical record to support the patient was reassessed to determine if the patient remained a risk to themselves or others. There are no notes in the medical record to determine why the patient was discharged or how the determination was made that the patient would not be transferred for inpatient psychiatric treatment. There are no notes to support the patient received psychiatric medications while waiting for transportation to stabilize their emergency medical condition. Discharge notes for the patient indicate the patient was diagnosed with suicidal ideation and chronic back pain. The discharge information does not indicate the patient was provided with outpatient resources or prescription medications to address their thoughts of suicide. The facility’s policy titled, Emergency Detention (ED) of Patients and Orders of Protective Custody (OPC), last revised/reviewed 11/20/2023, revealed: “Leaving Against Medical Advice: If a patient with unresolved medical needs and with suspected or diagnosed mental illness wants to leave UMC against medical advice (AMA), staff will follow the procedure in Section II.D.2. addressing restraints, or in absence of an order for restraints, will attempt to persuade the person to remain and the attending physician will assess the patient and document in a progress note whether, in the physician’s professional judgement and taking into consideration the full context of the patient’s mental and physical history and condition, to the extent known, the patient poses a substantial risk of harm to self or others due to mental illness. The policy supports that a reassessment should be documented for the patient if the patient poses a risk of harm to themselves or others. There are no notes to support that the patient was reassessed. Interviews In an interview on 9/25/2024 at 12:20 PM, Staff #7, Emergency Department Physician, indicated they provided the medical screening exam for patient #1. Staff #7 indicated that the patient initially came in for chronic back pain but in talking to the patient, it was determined that they had been experiencing thoughts of suicide because of the back pain. Staff #7 stated Patient #1 was “at their rope’s end” and appeared to be very agitated which caused Staff #7 concern. Staff #7 stated the patient was provided with a psychiatric assessment which revealed the patient required inpatient psychiatric treatment to address their thoughts of suicidal ideation. Staff #7 stated their shift ended at 6PM and prior to the end of the shift, the patient was secured a bed at the inpatient facility and was awaiting transport. Staff #7 indicated that they were not aware what occurred with the patient which allowed them to be discharged due to there not being any documented follow up. Staff #7 stated if the patient remained a threat to themselves and others and wanted to leave the facility, the physician will normally speak to the patient to persuade them to stay, and if they are adamant that they want to leave, the physician has an option to file an Emergency Detention Order (EDO). Staff #7 stated he would have expected for there to be a note in the patient’s medical record in the chart but there is lack of documentation. In an interview with Staff #1, Chief Medical Officer and Staff #3, Vice President of Quality, on the afternoon of 9/25/2024, Staff #3 and Staff #1 indicated that the patient’s medical record was reviewed and they determined that there was a lack of documentation by the physician which supported that a follow up assessment was completed and a determination was made regarding the patient being able to discharge home. Staff #1 stated, “the provider should have put the note in, but we cannot find the note. I would look at it as a missing documentation piece.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47578 Based on record review and interviews, the facility failed to comply with 489.24 when they did not provide stabilizing treatments within their capabilities for 1 of 20 patients (Patient #1). Patient #1 was determined to have an Emergency Medical Condition (EMC) when they were experiencing suicidal ideation and were deemed to be a danger to themselves or others. The facility failed to ensure the patient received appropriate treatment and allowed the patient to be discharged home while they were awaiting transportation to an inpatient psychiatric facility. Refer to A2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47578 Based on record review and interview, the facility failed to provide stabilizing treatments within their capabilities for 1 of 20 patients (Patient #1). Patient #1 was determined to have an Emergency Medical Condition (EMC) when they were experiencing suicidal ideation and were deemed to be a danger to themselves or others. The facility failed to ensure the patient received appropriate treatment and allowed the patient to be discharged home while they were awaiting transportation to an inpatient psychiatric facility. The findings were as follows: Record Review Patient #1’s medical record, dated 4/1/2024, revealed: Patient #1 presented on 4/1/2024 at 4:37 PM seeking treatment for back pain and suicidal ideation with a plan. The patient admitted to having a firearm and medications at home which could be used to achieve their desired outcome. The patient was provided with a psychiatric assessment which revealed that the patient was “an increased risk to themselves and others.” The patient voluntarily agreed to be transferred for inpatient psychiatric treatment due to the facility not having psychiatric services. The patient was provided with a sitter while awaiting transport to the inpatient facility and received a vital check (blood pressure, pulse, and oxygen) every hour. The inpatient facility arranged for the patient was two hours away therefore the facility encountered issues finding transportation. When the nurse returned to round on the patient’s vitals, the patient became agitated and indicated they wanted to leave. The nurse removed the patient’s IV, had them sign an AMA (against medical advice) form, and allowed the patient to leave. The patient is then documented back at the facility within 23 minutes. The medical record noted, “ Patient escorted back to ER room. Charge nurse notified patient he would have law enforcement called on him if he were to leave and an emergency detention order would be placed. Patient understanding and will cooperate with staff.” The patient remained at the facility for 7 more hours before being discharged on 4/2/2024 at 7:44 AM. The facility failed to follow their Leaving Against Medical Advice policy and did not reassess the patient to determine if the patient posed a substantial risk of harm to self or others due to mental illness. There are notes in the medical record supporting a reassessment was completed. There are no notes in the medical record to determine why the patient was discharged or how the determination was made that the patient would not be transferred for inpatient psychiatric treatment. There are no notes to support the patient received psychiatric medications while waiting for transportation to stabilize their emergency medical condition. Discharge notes for the patient indicate the patient was diagnosed with suicidal ideation and chronic back pain. The discharge information does not indicate the patient was provided with outpatient resources or prescription medications to address their thoughts of suicide. The facility’s policy titled, EMTALA Guidelines for UMC Health System’s Emergency Center, including the Health and Wellness Hospital’s Emergency Center, last revised/reviewed 7/19/2024, revealed: Patients with an Emergency Medical Condition: Once the MSE is completed and a determination is made that the patient has an EMC, UMC Heath System must either: 10.1.1 Stabilize/treat the patient’s EMC and then discharge from the Emergency Center (EC) if no further treatment is needed, 10.1.2 Admit the patient as an inpatient or in observation status if further treatment, which may include stabilizing the patient’s EMC, is needed, to 10.1.3 Transfer the patient to another medical facility to have the EMC stabilized if UMC Health System EC does not have the capacity or capability for the patient. 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 in the case of a woman in labor, that the woman has delivered the child and the placenta. The facility’s policy titled, Emergency Detention (ED) of Patients and Orders of Protective Custody (OPC), last revised/reviewed 11/20/2023, revealed: “Leaving Against Medical Advice: If a patient with unresolved medical needs and with suspected or diagnosed mental illness wants to leave UMC against medical advice (AMA), staff will follow the procedure in Section II.D.2. addressing restraints, or in absence of an order for restraints, will attempt to persuade the person to remain and the attending physician will assess the patient and document in a progress note whether, in the physician’s professional judgement and taking into consideration the full context of the patient’s mental and physical history and condition, to the extent known, the patient poses a substantial risk of harm to self or others due to mental illness. If the patient poses a substantial risk of harm to self or others due to mental illness, the physician will communicate the results of that assessment to nursing staff and/or UMC Police. If, despite staff’s effort’s, the patient elopes, staff will contact the appropriate law enforcement agency with information concerning the patients identify, condition, and location. If the patient no longer poses a substantial risk of harm to self or others due to mental illness, the ED will be voided, and the patient may leave AMA. If the patient would benefit from inpatient mental health treatment, physician and staff may still contact an inpatient mental health facility to attempt to arrange for placement despite the unresolved medical needs and encourage the patient to consent to transfer if the facility is willing to accept the patient. If the patient has not been detained under an ED but poses a substantial risk of harm to self or others due to mental illness, physician and staff will follow the procedure in Section II.D.2 addressing restraints and Section III addressing inpatient mental health treatment.” Section II.D.2 If restraints become necessary during the person’s stay, the use of restraints and seclusions will comply with SPP PC-26 “Restraints, Immobilization and Seclusion Adult/Pedi Patients’ Rights.” A physician will order the restraints or seclusion and must evaluate the person face to face within one hour of the application of restraints or initiation of seclusion. Interviews In an interview on 9/25/2024 at 12:20 PM, Staff #7, Emergency Department Physician, indicated they provided the medical screening exam for patient #1. Staff #7 indicated that the patient initially came in for chronic back pain but in talking to the patient, it was determined that they had been experiencing thoughts of suicide because of the back pain. Staff #7 stated Patient #1 was “at their rope’s end” and appeared to be very agitated which caused Staff #7 concern. Staff #7 stated the patient was provided with a psychiatric assessment which reveled the patient required inpatient psychiatric treatment to address their thoughts of suicidal ideation. Staff #7 stated their shift ended at 6PM and prior to the end of the shift, the patient was secured a bed at the inpatient facility and was awaiting transport. Staff #7 indicated that they were not aware what occurred with the patient which allowed them to be discharged due to there not being any documented follow up. Staff #7 stated if the patient remained a threat to themselves and others and wanted to leave the facility, the physician will normally speak to the patient to persuade them to stay, and if they are adamant that they want to leave, the physician has an option to file an Emergency Detention Order (EDO). Staff #7 stated he would have expected for there to be a note in the patient’s medical record in the chart but there is lack of documentation. In an interview with Staff #1, Chief Medical Officer and Staff #3, Vice President of Quality, on the afternoon of 9/25/2024, Staff #3 and Staff #1 indicated that the patient’s medical record was reviewed and they determined the patient did not leave AMA and were convinced to stay however there is lack of documentation to support that a physician assessment was completed and what the results of the assessment were. Staff #3 indicated that it is an assumption that the provider was at the bed side due to a nursing note for the patient dated 4/2/2024 at 7:00 AM and shortly after the patient was discharged home. Staff #1 further indicated that upon review, they found a physician who accessed the chart around the time of the discharge however the physician was not available for interview.”