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Based on interview and review of Emergency Department (ED) logs, 72 Hour Return logs, Medical Records, Staffing and Physician On-Call Schedules and a Police Report, the facility failed to provide a medical screening examination within its capacity and capability to one (Patient #1) of 21 patient records reviewed, who presented to the hospital Emergency Department (ED) for emergency care. The patient presented to the hospital intoxicated (first presentation), with possible ingestion of medication (overdose), and suicidal ideations (thoughts of killing self), after making cuts to her wrist, arm and neck. The patient was released to Law Enforcement custody, and while in Law Enforcement custody, continued to verbalize suicidal ideations throughout the day, and was returned to the hospital ED after she experienced an alcohol related seizure. The patient was admitted to observation status, and during her admission, continued to have thoughts of suicide, significant complaints of pain, and elevated blood pressures. The patient's continued thoughts of suicide, pain and elevated blood pressure were not addressed during the patients observation admission or stabilized before the patient was discharged to her home.

The hospital had the capacity and capability on the first presentation to complete a medical screening examination to further assess the patient's intoxication level and possible drug ingestion through blood work, as well as the patient's mental health through evaluation from a Mental Health Professional (MHP) who was available to the hospital's ED, as well as a Psychiatrist on-call. The facility also had the ability to stabilize the patient who appeared intoxicated, with suicidal thoughts and behaviors through medical detoxificatioin and availabe inpatient psychiatric care.

The hospital had the capacity and capability on the second presentation to complete a medical screening examination to include further assessment of the patient's suicidal thoughts, pain and elevated blood pressures, and to stabilize the patient to ensure no further deterioration could occur from her psychiatric and medical conditions.

Refer to A2406 and A2407 for details.



29511

Based on record review and interview, the hospital failed to provide a medical screening examination (MSE) within its capacity and capability to determine if one (#1) of 21 patients who presented to the hospital Emergency Department (ED) seeking care, suffered from an emergency medical condition (EMC), out of a sample selected from March 8 through April 11, 2016. The Emergency Department (ED) has an average of 3701 emergency visits per month.

Findings included:

Review of the facility policy titled, "Emergency Department Management of Behavioral Health Patients," dated 05/2014, showed that all patients presenting with signs and symptoms of behavioral issues and found to be in need of acute medical attention, those concerns will be addressed concurrent with behavioral health interventions.

Review of the facility policy titled, "EMTALA: Provision of Care," dated 03/2016, showed that each individual will receive a medical screening examination sufficiently detailed to determine whether he or she has an EMC. An EMC includes severe pain, psychiatric disturbances and substance abuse, such that the absence of immediate medical attention could reasonably result in serious jeopardy.

Review of Patient #1's ED record (initial visit) showed that the patient arrived to the ED by Law Enforcement on 04/09/16 at 12:53 AM. Staff A, ED Physician, documented examination at 1:19 AM, showed the patient had suicidal ideations after she had been drinking, and presented with multiple (self-inflicted) superficial cuts (cuts to the surface of the skin) to the wrist, forearm and left antecubital (region of the arm in front of the elbow, where blood is drawn), as well as several superficial neck abrasions. The patient's history, "limited as patient is intoxiated", showed depression and anxiety, drug abuse and alcoholism, with a previous suicide attempt after she jumped from a three story balcony. During the examination, the patient required a sternal rub (deep pressure applied to the center of the chest to produce pain) to wake the patient, but the patient still refused to answer any of Staff A's questions. At 1:32 AM, Staff A documented that the patient was fit for confinement (stable for incarceration), medically cleared for discharge (39 minutes after arrival), and released into law enforcement custody. The patient's was diagnosed with alcohol intoxication, suicidal ideation and lacerations of multiple sites of the left forarm.

During an interview on 04/13/16 at 9:30 AM, Staff B, Registered Nurse, stated that when Patient #1 arrived at the hospital with law enforcement, she struggled, and was non-compliant with the officer. When Staff B assessed Patient #1, he believed she was intoxicated and found multiple cuts to her left forearm and neck area, some of which had broken the skin. Staff B attempted to clean and bandage the wounds, but the patient fought with him, was non-compliant, and would not let staff touch her, or answer any questions. The patient's psychiatric stability was not assessed by a Mental Health Professional (MHP), and she was discharged to Law Enforcement, where she struggled and was non-compliant with the officer when she walked out of the ED.

During a telephone interview on 04/13/16 at approximately 10:00 AM, Staff A, ED Physician, stated that Patient #1 came to the ED in Law Enforcement custody. The patient was intoxicated, reported she had taken some of her psychiatric medications (alleged overdose), and was somnolent (strong desire to sleep) "from the alcohol, and possibly the drugs too". The patient required a sternal rub to wake, and when she woke, the patient refused to answer what drugs she took, how many she took, or when she took them. "She told us she wanted to kill herself, which was why she took the pills". "In a clinical standpoint, she was stable. She was intoxicated, but at the same time she was playing it up." Staff A stated he did not order laboratory tests on the patient and he did not know the patient's alcohol level, history, psychiatric history, or if she was taking her prescribed psychiatric medications before he discharged her to police custody. Staff A stated that he did not request a mental health professional to come and assess the patient's psychiatric stability, because her psychiatric stability would be addressed when the patient was discharged to police and placed on suicide watch at the jail. "She wasn't talking so there wouldn't have been much of an evaluation". and if she had been evaluated and required psychiatric admission, "it wouldn't have happened with her, because she was under arrest". Staff A stated that if the patient presented with the same symptoms, but was not in the custody of the police, "We would have to make sure (the patient's) ETOH (blood alcohol level) was less than 200 (80 is legally intoxicated), or hold them until it reaches less than 200, so they can be evaluated" by a mental health professional for possible psychiatric admission.

Review of staffing and on-call rosters for 04/08/16 at 7:00 AM through 04/09/16 at 7:00 AM, showed multiple MHPs were available to the ED for psychiatric assessments, as well as a Psychiatrist.

During an interview on 04/14/16 at 10:20 AM, Staff C, Lead Behavioral Health Assessor, stated that MHPs are available to the ED 24 hours a day, with a Psychiatrist on-call 24 hours a day. Staff C stated that they evaluate ED patients who have a behavioral health risk, especially those patients who verbalized suicidal ideation or have attempted suicide. Staff C stated that if the patient was intoxicated, Psychiatric Services would evaluate the patient once the patient's blood alcohol was less than 200 or when the patient was alert and oriented (understand and can verbalize) to person, place, time, and recent events. Staff C stated that if a patient was in the custody of Law Enforcement, MHP followed the same protocol as they would for a patient who was not in custody, and would assess the patient and contact the Psychiatrist on-call for potential admission. Staff C added that the facility had the ability to admit patients for psychiatric care who were in Law Enforcement custody through voluntary (agreeable to admission) or involuntary (refuses admission) admission.

The patient was documented as intoxicated, to the point she required a stermal rub to wake. The patient's history was limited as she refused to answer questions relevent to an appropriate MSE, but did express suicidal ideations, and presented with self inflicted injuries. The patient was discharged to Law Enforcement prior to a psychiatric assessment, which could have been completed once the patient was sober, as Behavioral Health Assessors and a psychiatrist were on call and available to the ED.

Review of Patient #1's medical record dated 04/09/16 (return visit) showed the following:
- The patient was taken from jail back to the hospital by a local ambulance at 11:08 PM, after the patient fell from a toilet and struck her head during a seizure that lasted approximately one minute.
- The patient reported that she drank a 5th of Vodka daily for the previous five years and had a history of withdrawal seizures.
- The patient initially declined treatment in the ED and did not want to be admitted, but when Staff I, RN went to discharge the patient, she requested to be admitted for alcohol detoxification.

- A signed affidavit received from the correctional facility on 04/10/16 at 12:13 AM, documented that on 04/09/16 at approximately 6:00 AM, 8:00 AM and at 9:30 PM, the patient stated she didn't care if she died and had no reason to live, and a Central Intake Assessor (BHP, Behavioral Health Professional) was contacted to completed a psychiatric assessment.

- Central Intake Assessment documentation showed she was a risk to self, after the patient reported she hated life and didn't see the point of living anymore, was suicidal with suicidal behaviors and planned to cut herself and hit an artery and die.
- The patient was admitted to observation with a diagnosis of alcohol intoxication, alcohol withdrawal seizure and suicidal ideation.

- The order for a psychiatric consult was not placed until 04/10/16 at 1:37 PM, approximately 14 hours after the patient's second arrival to the ED.

- A Psychiatric Examination on 04/10/16 at 1:54 PM by Psychiatrist D, documented that the patient was disheveled with elevated blood pressures, admitted she cut herself and drank alcohol to reduce chronic physical pain she felt, stopped taking her psychiatric medications when she was placed in jail (04/09/16), was anxious, and Staff D recommended that the patient transfer to psychiatric care when she was medically cleared, because she was not safe to discharge.
- The patient was documented to have significant pain and crying throughout her observation admission as well as elevated blood pressures.

- A Psychiatric Examination on 04/11/16 at 12:21 PM by Psychiatrist E, documented the patient's blood pressure was elevated at 146/105, there was no need for psychiatric admission, and the patient could be discharged when medically stable.
- There was no medical examination documented on 04/11/16.
- There was no blood pressure documented prior to discharge.
- The patient was discharged on 04/11/16 at 4:22 PM.

During a telephone interview on 05/25/16 at 6:30 PM, Central Intake Assessor K, stated she was called to the ED on 04/10/16 at 1:00 AM for a psychiatric assessment on Patient #1. The patient was sad and tearful and said that she hated life, did not want to live anymore and was cutting herself with a plan to hit an artery and die.

During a telephone interview on 05/14/16 at 6:30 PM, ED Physician A, stated that when the patient returned to the ED, she had an Emergency Medical Condition (EMC) based on seizure activity and suicide risk, but he did not request a psychiatric evaluation on the patient while she was in the ED, because the psychiatric evaluation would have been done inpatient. "Once they leave the ER (ED), I'm not involved with the patient or the patient's care". ED physician A added that the patient should have been admitted as a full admission, and if she wasn't, it was a mistake on his part.

During a telephone interview on 05/25/16 at 3:30 PM, Hospitalist J, stated that she was aware of the patient's elevated blood pressure, but believed it was related to the patient's alcohol withdrawal, and expected the patient's blood pressure to lower as the patient's withdrawal ended.

During a telephone interview on 05/24/16 at 7:40 PM, Psychiatrist D, stated that although she was the psychiatrist on call when Patient #1 returned, she wasn't consulted until 04/10/16 at 1:37 PM (approximately 14 hours after presentation) to evaluate the patient for her suicidality and chemical dependency. Psychiatrist D stated that during the evaluation, the patient was sedated due to detoxification medications, and Psychiatrist D was unsure if the patient's mental capacity was clear at the time, so she recommended the patient be admitted to Psychiatric Services once she was medically cleared and stable. "I felt she would engage in a better risk assessment once she was medically detoxed". Psychiatrist D stated that the patient had a significant psychiatric history with significant pain related to her previous suicide attempt (jumping off a three story building), and that she drank to help with the pain. Psychiatrist D also added that she believed Patient #1 had suddenly stopped her Gabapentin (medication to control pain or seizures), which placed the patient at seizure risk, and Paxil (medication used to treat depression), which can cause emotional instability.

During a telephone interview on 05/25/16 at 2:30 PM, Staff H, Case Management, stated that Patient #1 complained of pain and drank alcohol to control her pain.

During a telephone interview on 05/26/16 at 5:00 PM, Psychiatrist E, stated he saw the Patient #1 on 04/11/16 around 12:00 PM, as a psychiatric consult follow-up. Psychiatrist E stated he was aware of the patient's history, which included jumping from a three story building, and added that if the patient had pain or elevated blood pressure, it would be followed by the medical physician and not the psychiatrist. Psychiatrist E stated that he did not communicate with the medical physician before he cleared the patient psychiatrically.

During a telephone interview on 05/25/16 at 2:00 PM, Hospitalist G, stated that the only time he saw Patient #1 was the day she went home, that he examined her but did not document the examination in the medical record, and could not remember the examination. Hospitalist G stated that on the day of discharge, Patient #1's blood pressure was high at 148/104, but believed she was medically stable and could go home because, "They (nursing staff) did not call me at the time of discharge, so I assume that the patient's blood pressure was down."

During a telephone interview on 05/24/16 at 7:00 PM, Telemetry RN F, stated that she was the primary nurse for Patient #1 during the day shifts on 04/10/16 and 04/11/16 and discharged the patient. Telemetry Nurse F stated that the patient reported she had chronic pain from a previous suicide attempt where she jumped off a three story building, and drank alcohol to control the pain. Telemetry Nurse F stated that Patient #1's blood pressure was elevated through 04/10/16 at 7:18 PM, but added that there were no further blood pressures documented in the patient's medical record, and therefore could not determine if the patient's blood pressure was normal or remained elevated before she discharged the patient to her home by cab. Telemetry Nurse F did not know why there were no blood pressures documented in the medical record beyond 04/10/16.

The patient was documented to have elevated blood pressure and complaints of pain due to injuries sustained from a previous suicide attempt. The pain was so significant that the patient abused alcohol to control the pain. Neither the patient's elevated blood pressure, nor the patient's pain was evaluated and therefore, the MSE was not sufficient.

Based on record review and interview, the hospital failed to stabilize an Emergency Medical Condition (EMC) for one patient (#1) of 21 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical or psychiatric condition, out of a sample selected from March 8 through April 11, 2016. The Emergency Department (ED) has an average of 3701 emergency visits per month.
Findings included:
Record review of the facility policy titled. EMTALA: Provision of Care," dated 03/2016, showed that:
- An Emergency Medical Condition (EMC) was a medical condition manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The hospital will provide care within the extent of its capabilities to patients suffering from an EMC.
- Capability included services normally available to any patient in any area of the hospital, and included available ancillary services.
- Capacity included the ability to treat the patient, including availability of staff, beds, and equipment, and the hospitals past practices of accommodating additional patients in excess of its occupancy limits.

Record review of the facility policy titled, "Emergency Department Management of Behavioral Health Patients," dated 05/2014, showed that all patients presenting with signs and symptoms of behavioral issues and is found to be in need of acute medical attention, those concerns will be addressed concurrent with behavioral health interventions..

Patient #1's medical record dated 04/09/16 was reviewed and showed the following:
- The patient presented to the ED at 12:53 AM by Law Enforcement, after the patient had been drinking, expressed suicidal ideations and possible ingestion of several of her prescription pills.
- The patient was in the custody of Law Enforcement, who sought ED care to ensure that the patient was medically/psychologically stable for confinement in jail (fit for confinement).
- Nursing documented the patient was non-compliant, crying and tearful, had suicidal thoughts of cutting herself, a history of suicidal thoughts and was at immediate risk for suicide.
- The ED Physician documented the patient was unable to respond to questions about her medical or psychological history or current condition because she was intoxicated.
- The ED Physician documented he attempted a sternal rub on the patient, to wake the patient, but the patient still would not answer questions.
- The ED Physician documented the patient had multiple superficial cuts to her wrist, forearm and left antecubital (inner elbow) space, along with several superficial neck abrasions.
- The patient's diagnosis was alcohol intoxication, suicidal ideation and lacerations of multiple sites of left arm.
- The patient was discharged to jail on suicide watch at 1:32 AM (39 minutes after the patient arrived).

During an interview on 04/13/16 at 9:30 AM, Registered Nurse (RN) B, stated that when Patient #1 arrived at the hospital with Law Enforcement, he believed she was intoxicated and found multiple cuts to her left forearm and neck area, some of which had broken the skin.

During an interview on 04/13/16 at approximately 10:00 AM, ED Physician A, stated that Patient #1 came to the ED in Law Enforcement custody. The patient was intoxicated, reported she had taken some of her psychiatric medications, and was somnolent (strong desire to sleep) "from the alcohol, and possibly the drugs too". The patient required a sternal rub to wake, and when she woke, the patient refused to answer what drugs she took, how many she took, or when she took them. "She told us she wanted to kill herself, which was why she took the pills". Staff A added that if the patient required a psychiatric admission, "it wouldn't have happened with her, because she was under arrest".

During an interview on 04/14/16 at 10:20 AM, Lead Behavioral Health Assessor C, stated that the facility had the ability to admit patients for psychiatric care who were in Law Enforcement custody through voluntary (agreeable to admission) or involuntary (refuses admission) admission.

The patient was documented as intoxicated, to the point she required a stermal rub to wake. The patient's expressed suicidal ideations, and presented to the ED with self inflicted injuries. The patient was not stabilized prior to her discharge to Law Enforcement custody.

Review of Patient #1's medical record dated 04/09/16, showed the following:
- The patient fell from a toilet and struck her head during a seizure that lasted approximately one minute and returned to the ED.
- A signed affidavit received from the correctional facility on 04/10/16 at 12:13 AM, documented that on 04/09/16 at approximately 6:00 AM, 8:00 AM and at 9:30 PM, the patient stated she didn't care if she died and had no reason to live.

- Central Intake Assessment documentation showed she was a risk to self, after the patient reported she hated life and didn't see the point of living anymore, was suicidal with suicidal behaviors and planned to cut herself and hit an artery and die.

- The patient was placed in observation status on 04/10/16 at 12:00 AM, with a diagnosis of alcohol intoxication, alcohol withdrawal seizure and suicidal ideation.

- A Psychiatric Examination on 04/10/16 at 1:54 PM by Psychiatrist D, documented that the patient was disheveled with elevated blood pressures, admitted she cut herself and drank alcohol to reduce chronic physical pain she felt, stopped taking her psychiatric medications when she was placed in jail (04/09/16), was anxious, and Staff D recommended that the patient transfer to psychiatric care when she was medically cleared, because she was not safe to discharge.
- The patient was documented to have significant pain and crying throughout her observation admission as well as elevated blood pressures.
- A Psychiatric Examination on 04/11/16 at 12:21 PM by Psychiatrist E, documented the patient's blood pressure was elevated at 146/105, there was no need for psychiatric admission, and the patient could be discharged when medically stable.
- There was no medical examination documented on 04/11/16.
- The patient was discharged on 04/11/16 at 4:22 PM.

During a telephone interview on 05/25/16 at 3:05 PM, ED RN I, stated that Patient #1's blood pressure was elevated in the ED to 141/94 (normal range is less than 140/90).
During a telephone interview on 05/24/16 at 6:30 PM, ED Physician A, stated that when Patient #1 returned to the ED, she had an EMC based on seizure activity and suicide risk, and admitted the patient (to observation).
During a telephone interview on 05/25/16 at 6:30 PM, Central Intake Assessor K stated that when she assessed Patient #1, she was sad and tearful and said that she hated life, did not want to live anymore and was cutting herself with a plan to hit an artery and die.
During a telephone interview on 05/25/16 at 3:30 PM, Hospitalist J, stated that she was the admitting physician for Patient #1, and believed the patient had an EMC. Hospitalist J stated the patient's blood pressure was elevated, the patient had evidence of self-mutilation and reportedly made suicidal statements according to the jail workers.
During a telephone interview on 05/24/16 at 7:40 PM, Psychiatrist D, stated that when she evaluated Patient #1, she recommended the patient be admitted to Psychiatric Services. The patient had a significant psychiatric history with significant pain related to her previous suicide attempt (jumping off a three story building), and she drank to help with the pain. Psychiatrist D also added that she believed Patient #1 had suddenly stopped her Gabapentin (medication to control pain or seizures), which placed the patient at seizure risk, and Paxil (medication used to treat depression), which can cause emotional instability.
During a telephone interview on 05/25/16 at 2:30 PM, Case Management Staff H, stated that Patient #1 changed from observation status to full admit on 04/11/16 at 12:00 PM by Hospitalist G. Staff H added that the patient complained of pain and that she drank to control her pain.
Record review of "ADT Orders" showed that the patient was admitted as an inpatient on 04/11/16 at 12:00 PM.
During a telephone interview on 05/26/16 at 5:00 PM, Psychiatrist E, stated he saw Patient #1 on 04/11/16 around 12:00 PM and released her to the care of medical services. Psychiatrist E stated that if the patient experienced abnormal vital signs, such as an elevated blood pressure, or pain, it "falls back to the medical doctor".
During a telephone interview on 05/25/16 at 2:00 PM, Hospitalist G, stated he examined Patient #1 on 04/11/16 and discharged her, but did not document the examination in the medical record, and could not remember the examination. Hospitalist G stated that on the day of discharge, Patient #1's blood pressure was elevated (148/104), but assumed the patient's blood pressure went down before she was released from the hospital.
During a telephone interview on 05/24/16 at 7:00 PM, Telemetry RN F, stated that she was the primary nurse for Patient #1 during the day shifts on 04/10/16 and 04/11/16. Telemetry RN F stated that the patient reported she had chronic pain from a previous suicide attempt where she jumped off a three story building, and drank alcohol to control the pain. Telemetry RN F added that Patient #1's blood pressure was elevated throughout the patient's observation admission.
Record review of the Psychiatrist on-call schedule, showed that a Psychiatrist was on-call and available to the ED for psychiatric evaluations during the Patient #1's first and second presentation.

Record review of the psychiatric unit census for 04/09/16 through 04/11/16, showed there was capacity for the patient to be admitted to a psychiatric unit during Patient #1's first and second presentation.

The facility failed to stabilize the patient's EMC which included elevated blood pressures and significant pain.