HospitalInspections.org

Based on a medical record review, Police report review, Facility's Behavioral Health Contract review, video surveillance footage review, Medical Staff Rules and Regulations review, Behavioral Health Contract schedule review, Central Log review, interview with local law enforcement, interviews with facility staff, and a review of policies and procedures, it was determined that the facility failed to provide an appropriate medical screening exam 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 existed for 1 (Pt.#1) of sampled patients, who presented to the emergency department (ED)with active suicidal ideations.


Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening exam.

Based on a medical record review, Police report review, Facility's Behavioral Health Contract review, video surveillance footage review, Medical Staff Rules and Regulations review, Behavioral Health Contract schedule review, Central Log review, interview with local law enforcement, interviews with facility staff, and a review of policies and procedures, it was determined that the facility failed to provide an appropriate medical screening exam 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 existed for 1 (Pt.#1) of sampled patients, who presented to the emergency department (ED)with active suicidal ideations.

Findings:

A review of the facility's Central Log revealed that Patient (P) #1 presented to the Emergency Department (ED) and was registered as a patient on 10/16/2022 at 4:10 am.

A review of Patient (P) #1 medical record revealed that P#1 initially presented to the facility's Emergency Department (ED) on 10/16/2022 at 4:10 am for medical clearance after being in a motor vehicle accident while running from eluding police in a stolen vehicle. P#1 reports suicidal thoughts, and he considered banging his head, going out into traffic, or swallowing glass. Further review of P#1 medical record revealed that P#1 reported hearing voices and they are telling him to hurt himself. P#1 denies any past medical history or psychiatry history.

At 4:31 am. the Triage started; the Registered nurse (RN) CC noted that P#1 presented to the ED for medical clearance. P#1 triage acuity was three (3).

At 4:34 am. The emergency physician (EP) (DD) was assigned to P#1. Orders placed by EP DD included Lab Orders (urine drug screen, urinalysis, salicylate, ethanol, comprehensive metabolic panel, complete blood count). Diagnostic tests performed were Imaging (Head computer tomography, X-ray pelvis, chest).

AT 4:59 a.m., review of the 'ED Provider Notes', written by Emergency Physician (EP) DD, revealed that a 1013 (involuntary mental health hold- it authorizes a 72-hour involuntary hold also known as 72-hour Rule ... is called a "1013" because form is completed by the assessing physician (or other Health Care professional) https://www.ezelderlaw.com) was signed for P#1. The 1013 revealed in part, "This individual appears to be mentally ill, person requiring involuntary treatment ...appears ... Presents a substantial risk of imminent harm to self and others as manifested by recent overt acts or recent expressed threats of violence ...for example Suicidal ideations."

The section of the Medical Record titled "Re-Assessment" Documentation by EP DD revealed in part, the patient reported having suicidal ideation, reported he tried to kill himself "by banging his head against the wall ...reported he is(sic) attempted suicide in the past by walking into traffic with the hopes of being struck by a car. .. The patient is medically cleared but not psychiatrically cleared. Patient was discharged with a 1013 into police custody. Patient can follow-up with a psychiatrist for evaluation of the suicidal ideation while in jail. Review of the medical record (MR) revealed the Medical Screening Examination (MSE) was not complete on the patient's initial visit to ED on 10/16/2022. The ED physician (EP DD) who initially saw patient #1 documented in the MR that another provider was consulted, however it does not say who. Additionally, there was no documentation in the MR on the initial visit the patient's psychiatric condition was assessed /evaluated, nor that contracted service was consulted to provide an evaluation of PT.#1's psychiatric problems that were identified; and despite the patient still being on IVC (Involuntary Commitment) status.

At 5:07 am. RN CC completed the suicide risk assessment and documented that P#1 had active suicidal ideation with a specific plan and intent. RN CC documented that MD was notified for the needed psychiatric consult and/or possible 1013 form executed; 1:1 constant observation was initiated.

P#1 vital signs at 5:11 am were as follows: temperature 98.1 degrees (normal 97.5 to 99.0) Fahrenheit, heart rate- 83 beats per minute (normal 60 to 100 beats per minute), respiratory rate-20 breaths per minute (normal-12 to 20) blood pressure 109/59 (normal 120/80), pulse oximetry (the amount of oxygen in the blood) 97%.

At 7:06 am, P#1's urine sample was collected to test for sexually transmitted infections, and he was administered an intramuscular (inside muscles) antibiotic.

At 7.27 am, EP DD discharged P#1 and ordered oral antibiotics for P#1.

At 7.41 am, CN BB documented that P#1's report was given to a deputy at a nearby jail, further review revealed that CN BB noted P#1 has been medically cleared by EP DD and discharge paperwork and a complete 10-13 was given to the Sergeant (S) FF.

A review of the video surveillance footage took place on 11/02/2022 at 12:27 pm with the Manager of Public Safety in his office.
On 10/16/22 at 07:44 am, P#1 was observed coming out with two law enforcement officers from the emergency room through the ambulance bay into the law enforcement vehicle

At 8:25 am: Law enforcement officers were observed in their vehicle still at the ambulance entrance with P#1 at the back of the car.

At 8:59 am a registered nurse was observed heading toward the law enforcement officer, at 9:00 am, P#1 was observed with law enforcement officer going back into the emergency department.

At 9:00 am, CN BB noted that P#1 was transferred to an ED room, CN BB documented that S FF returned to the ED with P#1 and reported that P#1 was no longer in custody. P#1 was escorted to a room in the ED. AT 9:15am ED HH (oncoming ED physician) completed and signed another 1013 Form dated 10/16/22 at 9:15 a.m. This 1013 form indicated that Patient #1 was mentally ill and was requiring Involuntary treatment. The form also specified in part," Appears to be unable to care for self on his own physical health and safety as to create imminently life endangering crisis ...At the time of my evaluation ...my opinion is based on the following observations: Suicidal thoughts and voices."

At 9:35 am, EP HH ordered a consultation with the psych assessment team.

At 12:02 pm, EP HH documented that he spoke with the mental health psych assessment team. He was informed that P#1 does not require 1013 for suicidal thoughts. EP HH noted that P#1 was in police custody, medically cleared, and may be discharged to jail. EP HH documented that 1013 will be rescinded for P#1 to be discharged to jail on suicide watch.

AT 12:03 p.m., EP HH Hand written over the 1013 form was the word "RESCINDED" signed by EP HH at 12:03, rescinding the 1013.
A review of the psych assessment by the licensed professional counselor (LPC) GG on 10/16/2022 at 12:44 pm revealed that P#1 was brought to the ED for medical clearance. P#1 was in a car chase with the police. P#1 was in a stolen vehicle and was pitted by police. P #1 states he has suicidal ideation and plans to kill himself by banging his head. LPC GG documented on suicide risk evaluation that P#1 was not suicidal. LPC GG's diagnostic impression was schizophrenia and bipolar and recommended outpatient/community referral. Further review revealed that P#1 was medically cleared, 1013 was rescinded, on the second visit, and LPC GG noted that P#1 would be discharged to the police department.

At 1:17 pm, EP HH documented that the police department was contacted by CN BB that P#1 is of 1013 and ready for discharge back to jail. EP HH noted that CN BB was informed that P#1 is free to go home at this time.


At 1:18 pm, the case manager (CM) KK documented that P#1 had been cleared for discharge by medical and mental health providers. P#1 had been cleared for discharge to the community per law enforcement. P#1's car was totaled, and P#1 stated he does not have transportation home, and P#1 was assisted with uber transportation.
The facility's Professional Behavioral Health Service Contract Agreement dated 7/30/2018 was reviewed. The Contract revealed that the behavioral health facility will furnish behavioral health consultation, evaluation, assessment, stabilization, transfer, treatment, and follow-up professional service to inpatient and outpatients of the Hospital.

The facility's Professional Behavioral Health Service 's Contract Agreement schedule for 10/22 was reviewed. The schedule revealed that an individual was available to provide a psychiatric assessment/evaluation for patient #1 when he presented to the facility on 10/16/22. The 's facility's ED failed to provide an appropriate MSE within the capability of the facility's ED including ancillary services (Behavioral Health Contractor) that were routinely available to the ED when Patient #1 presented to the ED initially on 10/16/2022.


A review of the Police "Case Report" dated 10/17/22 at 6:40 a.m., revealed in part, " On Sunday 10/16/2022 at approximately 0616 hours, I responded to Rockdale Piedmont ...attempting to get Patient #1 medially cleared so he could be transferred to the county jail. While at the hospital I was notified the on duty Doctor signed a 1013 ...Pt.#1 made statements that he wanted to hurt himself ...Officer ...advised the hospital staff was in the process of rescinding the 1013 but then the Doctor changed his mind ...Due to Pt.#1 needing psychiatric treatment , staff would need to obtain assistance before we transported ...Patient #1 to jail ...the Charge Nurse stated they were not a psychiatric emergency facility ...and will need to transport the patient to the county jail ...I explained to the Charge Nurse that jail was not an emergency receiving facility and that Patient #1 needed to be evaluated at the hospital, due to the MD signing the 1013 ...CN stated he contacted ...Deputy at jail at approximately 0730 hours whom stated they would accept patient #1." Further review revealed that "Due to the nature and issues at Rockdale Piedmont we allowed him (Pt.#1) to leave and not place him in custody at this time."

A review of the facility's policy titled "Admission to Emergency Services,50043", policy number 9923008, last reviewed 7/22/21, revealed that any individual can come to the facility's emergency department and request an examination or treatment for a medical condition. The facility's emergency department will provide an appropriate medical screening examination to determine whether or not an emergency medical condition exists. This screening requirement encompasses the use of ancillary services routinely available to the ED. If a determination is made that no emergency medical condition exists, there is no mandate for the Hospital to provide further treatment to a patient.
Procedure:
1. Emergency medical condition is defined to include any condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonable be expected to result in any of the following: placing the health of the individual or an unborn child in serious jeopardy: serious impairment of bodily functions or serious dysfunction of
any bodily organ or part.

The facility policy titled "Care of Behavioral Health Patients" policy number 9270310, last revised 2/10/21, was reviewed. The policy revealed, the facility is an acute care hospital and is not an emergency receiving emergency treatment (ERET) facility. Patients accessing care at the facility who require psychiatric treatment will be managed through referral and transfer to a receiving psychiatric facility and/or managed through consultative psychiatric services on a temporary basis. It is the facility's policy to honor and promote a patient's rights of autonomy and self-determination while balancing such rights with the need to keep patients, staff and visitors safe. The facility will not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate has been executed. However, if in the physician professional judgement, a patient's recent actions or statements are of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represent an immediate threat of harm to the patient or to others, that patient may be held against his or her will pending transfer to an emergency receiving facility as a safeguard measure, for as long as the immediate threat persists.

The facility's Medical Staff Bylaws, Policies and Medical Staff Rules and Regulations, Adopted April, 2019 was reviewed. The Rules and Regulations section 11. B Medical Screening Examination revealed in part, "(1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition."
Interviews:

An interview took place with the Sergeant (S) FF on 11/2/2022 at 2:30 pm in the conference room. S FF explained that P#1 was presented to the ED after being involved in a car accident. P #1 had a stolen car, officers hit the car, and two people were arrested and brought to the ED for medical clearance before going to jail. P#1 told the EP DD he had suicidal thoughts and EP DD signed a 1013 and discharged P#1. The charge nurse (CN) BB gave the officer the 1013 and said P#1 would be taken to jail. S FF said she and other officers contacted the jail, and they refused to take P#1 because of his suicide ideation and 1013. S FF said that she witnessed P#1 telling CN BB that he wanted to kill himself. S FF said CN BB ignored and said P#1 is medically cleared and should be taken to jail. S FF said the hospital security left P#1 in the room to be watched by the police. S FF explained that the officer took P#1 and placed him in the police car, and contacted the jail captain, who said they couldn't take P#1 if he was suicidal. S FF said the officer took him back into the ED. S FF said the Hospital accepted P#1 and placed him in a room. S FF acknowledged that P#1 was placed in a police car at the parking lot, and they didn't take him to jail before sending him back into the Hospital's ED. S FF said that while P#1 was in the police car he said he had a psychiatric history. S FF said after taking P#1 back into the ED, they left the Hospital. S FF said around 12:00 pm, CN BB called the police and said the Hospital had rescinded P#1's 1013. S FF said they told CN BB that P#1 needed a medical evaluation. S FF said the Hospital released P#1 in an uber. S FF said after dropping P#1, the uber driver came to the police department crying that P#1 had threatened her, making statements about her legs. The Uber driver was scared, thinking P#1 would choke and kill her. S FF said the Hospital failed to medically examine P#1 and just released him to the community. S FF said she has a lot of incidences where the Hospital had released patients on 1013 (involuntary admission) to the community without medically assessing and caring for them. S FF said the Hospital had an impression that a person who committed a crime did not deserve medical care but jail.

An interview took place with the charge nurse (CN) BB on 11/2/2022 at 3:04 pm. CN BB explained that when he came in to work about 5:30 am the morning of the incident he received a shift report from the night shift nurse about a patient at the facility for medical clearance. P#1 eluded the police and had to do pit maneuvers to stop the patient. CN BB said he was told P#1 was at the ED for medical clearance and, at some point, said he was suicidal, which made the physician write 1013. CN BB said he was told P#1 would be cleared and released to jail. CN BB said once the lab work was completed, EP DD discharged P#1. CN BB collected the paperwork and contacted the jail. CN BB explained that the jail expressed no problem taking P#1 with a 1013. CN BB explained that the jail dealt with several patients on a1013, and in his previous job experience, there have been numerous occasion patient was transferred to the jail on a 1013. CN BB said the jail had people that evaluated behavioral health patients and that the jail had a mobile behavioral health assessor. CN BB said he gave the discharge paperwork and the signed 1013 to the officers. However, the officer refused to take 1013, stating they were not going to transport the patient. CN BB said he explained that P#1 had been medically cleared and the police officer took P#1 outside in handcuff for over an hour before bringing him back into the ED and P#1 was placed in a room. CN BB said that the emergency physician (EP) HH ordered mental health assessment for P#1, and the assessor recommended that P#1's 1013 be rescinded. The assessor said they do not need to take P#1 into an inpatient psychiatric facility.


An interview took place with the registered nurse (RN) JJ on 11/2/2022 at 4:19 pm. RN JJ explained that he got a report that P#1 was at the Hospital for medical evaluation, and upon arrival, he complained of suicidal thoughts and dysuria. He was evaluated by EP DD and was medically cleared with 1013. P#1 was discharged to police custody to be taken to jail after he had been treated for his urinary tract infection. RN JJ said he was not sure what occurred but saw the police bringing back P#1, and P#1 was placed in a behavioral room at the ED.


An interview with the paramedic (PMD) II took place on 11/2/2022 at 4:35 pm. PMD II explained that P#1 was in the behavioral health pod, and she was with him when he came back the second time. PMD II said P#1 was not in her care for long before the psychiatry assessment team and EP HH rescinded the 1013 and P#1 was later discharged from the facility. PMD II said that the police were informed that P#1's 1013 had been rescinded, but the police said P#1 was free to go. P#1 was discharged, walked out of the facility and PMD II never saw him again.

An interview with the licensed professional counselor (LPC) GG took place on 11/3/2022 at 9:59 am. LPC GG explained that she remembered P#1. P#1 was brought to the ED for medical clearance before he was taken to jail. P #1 complained of suicidal ideation and was placed on 1013. LPC GG said she did his assessment (Second visit), and P#1 was medically cleared to be taken to jail. LPC GG said she recommended to the emergency physician that 1013 should be rescinded. However, the police claimed they could not pick P#1 up, so he was discharged.


A telephone interview with the emergency physician (EP) DD took place on 11/3/2022 at 10:36 am. EP DD explained that P#1 came in with a motor vehicle collision and needed to be medically cleared. EP DD said P#1 was medically cleared; however, during his assessment, P#1 said he wanted to hurt himself, so he wrote 1013. EP DD said he was under the impression that once P#1 was medically cleared he could get the psychiatry assessment done in jail. EP DD said in other states he had worked, it was common to conduct psychiatry assessments, and there was an assessor in jail. EP DD said he spoke with the jail nurse and thought the patient was going to be discharged and go to jail. EP DD said P#1 medical condition was stable. EP DD said he was not aware when P#1 was brought back to the Hospital as he had already completed his shift.
A telephone interview took place with the emergency physician (EP) HH on 11/3/2022 at 12:08 pm. EP HH explained that P#1 was seen by EP DD and was medically cleared. P#1 had suicidal ideation, and CN BB was under the impression since P#1 was medically cleared, he could go to jail. However, the police brought him back for repeated evaluation. EP HH said he placed P#1 on a 1013 and consulted the psychiatric assessment team. The team recommended rescinding 1013, and there was no recommendation to transfer P#1 to an inpatient psychiatry facility. EP HH said from a clinical standpoint that P#1 was medically cleared, and based on the recommendation from the mental health assessor, there was no other necessary stabilizing treatment that P#1 needed from the emergency department