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Based on record review and interview the hospital's Emergency Department failed to comply with §489.24(r) and §489.24(c) and provide an appropriate medical screening examination to determine the existence of an emergency medical condition for one of one patient (Patient #1). Patient #1 was highly suicidal, agitated, and verbally abusive towards staff. After spending twelve minutes with ED staff, Patient #1 was escorted off the premises. Less than 24 hours later, Patient #1 returned to the ED stating he heard voices that told him to kill himself.




Cross Refer to A2406 CFR 489.24(a) and 489.24(c).

Based on record review and interview, the hospital's Emergency Department (ED) failed to provide an appropriate medical screening examination for one of one patient (Patient #1) who was highly suicidal, agitated, and verbally abusive towards staff. After spending twelve minutes with ED staff, Patient #1 was escorted off the premises. After the incident, staff unsuccessfully attempted to locate the patient. Less than 24 hours later, Patient #1 returned to the ED stating he heard voices that told him to kill himself.

Findings included:

Patient #1's Emergency Department Arrival Information dated 09/26/16 at 2328 reflected a chief complaint of "Agitation...assumed psych complaint..."

Patient #1's ED Triage Notes dated 09/26/16 at 2328 reflected Patient #1 was at "high risk" for suicide and placed on one-to-one staff observation for suicide precautions. The document noted to activate psychiatric services and notify the provider. The document reflected Patient #1 was not to leave the hospital.

Patient #1's ED Nursing Notes dated 09/26/16 at 2329 reflected Patient #1 was "...uncooperative and agitated...endorses suicidal ideations...will need to evaluate for APOWW [Apprehended by Peace Officer Without a Warrant]..."

Patient #1's ED Provider Notes dated 09/26/16 at 2338 reflected Patient #1 "arrived...immediately yelling at staff...threatened [staff]...awake, alert, no distress ...regular respirations without increased respiratory effort...moving all extremities ...steady gait, unassisted...Patient escorted from pod by...[Hospital] Police." There was no documented evidence of a medical screening examination including ancillary services to determine whether or not an emergency medical condition existed.

Patient #1's ED Disposition dated 09/26/16 at 2340 reflected Patient #1"...left before treatment complete..."

ED Nursing Notes dated 09/27/16 at 2210 reflected Patient #1 walked into the ED stating that voices were telling him to kill himself.

During a telephone interview on 10/12/16 at 1635, Employee #4 stated Patient #1 was triage assessed to be high risk for suicide and findings were documented in the patient's record.

Employee #13 stated during a telephone interview on 10/12/16 at 1640 that she "did not witness" a medical screening exam was conducted on Patient #1.

Employee #15 stated during a telephone interview on 10/13/16 at 0930 that Patient #1's 09/26/16 medical screening was "adequate." Employee #15 denied awareness of Patient #1's high suicide screening score before the patient's ED departure.

Employee #12 stated during a telephone interview on 10/13/16 at 0940 that Patient #1 "was not a medical emergency and was escorted off the premises with steady gait and in no distress..." Employee #12 denied awareness of Patient #1's suicide assessment score until after the patient left the hospital.

During an interview on 10/07/16 at 1500, Employee #8 stated that on 09/26/16 Patient #1 was police escorted off the premises. Upon return to the ED, the officer was informed that the patient needed psychiatric evaluation. The officer unsuccessfully attempted to locate Patient #1.


Employee #10 was asked during an interview on 10/11/16 at 1440 why Patient #1 did not receive a psychiatric evaluation after his high suicide screen score and stated she did not have an answer. Employee #10 stated that the incident "was escalated to management that night" and staff was sent out to look for Patient #1.

The Hospital's Patient Transfer and Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Policy (Admin 3-06) dated 01/21/16 noted that "any individual who comes to the ...[Hospital] property requesting assistance for a potential emergency medical condition or emergency services will receive an appropriate medical screening examination ...to determine if an emergency medical condition exists."