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Based on observations, interviews and record reviews, it was determined the facility failed to comply with 42 CFR 489.24(r) and 489.24(c) in regard to providing an appropriate medical screening within the capability of the hospital's emergency department (ED) and 42 CFR 489.24(d)(1-3) in regard to providing a patient with an emergency medical condition, further examination and treatment required to stabilize the medical condition for one patient (#1) in the selected sample of 21. The facility failed to ensure their policies "EMTALA - Emergency Medical Treatment" and "Transfer/Receiving Patients According to COBRA" were followed. Findings include:

Review of the facility policy "Transfer/Receiving Patients According to COBRA" revealed "Every person presenting to the Emergency Department shall receive an appropriate medical screening examination. This examination must be sufficient to determine if the person has an emergency medical condition." Review of the facility policy "EMTALA - Emergency Medical Treatment" revealed "the initial medical screening examination must be conducted by qualified medical personnel to determine with reasonable confidence whether an emergency medical condition exists. The medical screening examination should be an ongoing process accompanied by a record that reflects continuous monitoring of the patient. An emergency medical condition is a condition whose acute symptoms are severe enough that without immediate medical attention, it is expected to jeopardize the health of the individual, seriously impair bodily function, or cause serious dysfunction of any organ or body part. Symptoms include pain, psychiatric disturbances, and substance abuse."

Observations of a video of Patient #1 taken on 03/19/11 in the Emergency Department (ED) revealed the following: Patient #1 entered the behavioral health room in the ED and sat down on the end of the stretcher. Patient #1's hands were cuffed and his/her legs were shackled. Outside of the room was a Deputy Jailor and a facility Security Officer. Observations revealed Patient #1's assigned ED Physician (ED Physician #2) was observed for 36 seconds in the hall area outside of Patient #1's ED room. During the 36 seconds ED Physician #2 was talking with the Deputy Jailor in the hallway, then moved into the doorway where Patient #1 could be viewed for 4 seconds, and then he left the area. On a second occasion Physician #2 came to the doorway of Patient #1's ED room and looked into the room for 5 to 6 seconds and walked off. Neither of the times that ED Physician #2 came to the doorway of Patient #1's ED room did the physician have a conversation with Patient #1 or conduct an examination.

A review of Patient #1's ED medical record for 03/19/11 revealed he/she presented to the ED at 1437 accompanied by the police (from jail). The police had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was brought to the facility ED by order of the County Attorney.

An interview with ED Physician #1 on 03/29/11 at 2:15 PM, revealed he was staffed in the ED on 03/19/11 when Patient #1 was in the ED but he did not perform a medical screening on Patient #1. He stated ED Physician #2 was the assigned physician to Patient #1 on 03/19/11.

An interview with ED Physician #2 on 03/29/11 at 3:35 PM, revealed the medical screening consisted of "primarily a mental evaluation." He stated he did not review any of Patient #1's previous ED and/or hospital admissions. He stated initially there was no conversation with Patient #1 because it was "obviously pointless." He stated he could not ask Patient #1 any questions or do a formal evaluation. After the medication was given and Patient #1 began calming down he stated he looked in on Patient #1 but did not examine the patient. ED Physician #2 stated he felt Patient #1 was oriented and coherent. He felt she was "clearly not suicidal." He stated he did not call Behavioral Health to assess because he felt that Patient #1 knew what he/she was saying.

An interview with the Deputy Jailor on 03/30/11 at 11:45 AM, revealed Patient #1 was brought to the ED on 03/19/11 for a mental evaluation because Patient #1 had been throwing food in the jail, washing his/her hair with toilet water, not sleeping, acting bizarre, talking out of his/her head making statements about being pregnant with twins, and talking about the devil. The Deputy Jailor stated he did not observe the attending ED Physician (ED Physician #2) go into the room and examine or talk to Patient #1 anytime during the ED visit. After returning to the jail Patient #1 slept through the night. The next day Patient #1's behavior began escalating again. After the effects of the medication, that was administered in the ED wore off, Patient #1 began screaming out and talking about being pregnant again. Patient #1 required tazing on 03/20/11 due to his/her behavior. On 03/21/11 Patient #1 was evaluated by a Mental Health Professional and Patient #1 was sent to a psychiatric hospital for admission.

The facility failed to ensure their policies "EMTALA - Emergency Medical Treatment" and "Transfer/Receiving Patients According to COBRA" were followed in regard to conducting an appropriate medical screening examination to determine if an emergency medical condition existed for Patient #1. The failure resulted in Patient #1 being tazed while in jail and sustaining bruising and black eyes from head banging. Additionally, the facility failed to provide further psychiatric examination, treatment, and stabilization for Patient #1 on 03/19/11.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure one patient (#1) in the selected sample of 21 received an appropriate medical screening examination within the capability of the hospital's emergency department (ED). The facility failed to follow their policies "EMTALA - Emergency Medical Treatment" and "Transfer/Receiving Patients According to COBRA" resulting in Patient #1 not receiving an appropriate medical screening to determine if an emergency medical condition existed. Findings include:

Review of the facility policy "Transfer/Receiving Patients According to COBRA" revealed "Every person presenting to the Emergency Department shall receive an appropriate medical screening examination. This examination must be sufficient to determine if the person has an emergency medical condition." Review of the facility policy "EMTALA - Emergency Medical Treatment" revealed "the initial medical screening examination must be conducted by qualified medical personnel to determine with reasonable confidence whether an emergency medical condition exists. The medical screening examination should be an ongoing process accompanied by a record that reflects continuous monitoring of the patient. An emergency medical condition is a condition whose acute symptoms are severe enough that without immediate medical attention, it is expected to jeopardize the health of the individual, seriously impair bodily function, or cause serious dysfunction of any organ or body part. Symptoms include pain, psychiatric disturbances, and substance abuse."

A review of the medical staff rules and regulations revealed the "EMTALA related medical screening examination" could be performed by the following: The ED Physicians, the ED Physician's Assistants, and the ED Advanced Registered Nurse Practitioners. Additionally, the obstetric nurses were authorized to perform the medical screening examination for pregnant patients at 20 weeks or greater gestation.

A video of Patient #1 taken on 03/19/11 in the Emergency Department (ED) was provided by the facility for surveyor review. Review of the video revealed it did not contain audio nor was there the ability to know what time events took place. There was a minute and second counter on the video. The video encompassed the entire time Patient #1 was in the ED. Observations of the video revealed the following: Patient #1 entered the behavioral health room in the ED and sat down on the end of the stretcher. Patient #1's hands were cuffed and his/her legs were shackled. Outside of the room was a Deputy Jailor and a facility Security Officer. ED staff entered the room and obtained vital signs. Patient #1 could be observed with his/her mouth moving. ED nursing staff performed a nursing assessment. An ED Nurse Technician was present in the room with Patient #1 when Patient #1 came to a standing position and lunged toward the female staff. A facility Security Officer intervened. Patient #1's mouth was continually moving. Patient #1's assigned ED Physician (ED Physician #2) was observed for 36 seconds in the hall area outside of Patient #1's ED room. During the 36 seconds ED Physician #2 was talking with the Deputy Jailor in the hallway (not looking in the room where Patient #1 was located), then moved into the doorway where Patient #1 could be viewed for 4 seconds, and then he left the area. There was no conversation between ED Physician #2 and Patient #1 nor was an examination performed. Three ED nursing staff and a Security Officer entered Patient #1's room. Patient #1 stood up, leaned over the stretcher, and permitted the staff to administer two injections of medications in the buttocks area. Another ED physician (Physician #1), who was not treating or involved in Patient #1's care, entered Patient #1's room, 1.5 minutes after the medications were administered. ED Physician #1 was observed rushing into the room and making statements to Patient #1, while raising his arm and pointing his finger at Patient #1. ED Physician #1 started to leave the room when Patient #1 said something. Physician #1 abruptly turned around and went back toward Patient #1. ED Physician #1 placed his left hand on Patient #1's neck and upper chest area and pushed Patient #1 down on the stretcher. ED Physician #1 left Patient #1's ED room and did not return while Patient #1 was in the ED. Later after Patient #1 calmed down and was lying quietly on the stretcher, ED Physician #2 (attending physician) came to the doorway of Patient #1's ED room and looked into the room for 5 to 6 seconds and walked off. There was no conversation between Physician #2 and Patient #1 nor was an examination performed. ED Physician #2 did not come to the doorway or enter Patient #1's room at any other time while Patient #1 was in the ED. A meal tray was served to Patient #1. Patient #1 was calm and consumed his/her meal tray without any further incidents. Patient #1 was observed calmly walking out of the ED accompanied by the Deputy Jailor.

A review of the history of Patient #1's visits to the facility's ED and admissions to the facility revealed Patient #1 had been admitted to the facility's psychiatric unit on 03/23/09 through 04/01/09 with the diagnosis of "Psychosis." Patient #1 had been experiencing auditory hallucinations (hearing voices).

A review of Patient #1's ED medical record for 03/19/11 revealed he/she presented to the ED at 1437 accompanied by the police (from jail). The police had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was brought to the facility ED by order of the County Attorney. Review of the "Focused Nursing Assessment" revealed Patient #1 was agitated and cursing loudly. His/Her face was red from pepper spray. Patient #1 stated his/her skin was burning from the pepper spray. Review of Physician #2's documentation revealed Patient #1 was "very angry, combative, cursing, and yelling." Additionally, ED Physician #2 documented that Patient #1 was uncooperative for an exam, hostile, unable to determine orientation, normal motor and sensory response, normal inspection of neck and back, no respiratory distress, normal skin color, no rash, no signs of injury to the extremities. ED Physician #2 documented Patient #1 was on a 72 hour emergency hold due to danger to self and potentially violent. Patient #1's past history was "bipolar disorder." The clinical impression was "agitation" and the physician documented that he counseled Patient #1 on the diagnosis and need for follow-up. Review of the Medication Administration Record revealed that on 03/19/11 at 1450 Patient #1 received Geodon 20 mg intramuscular (IM) and Ativan 2 mg IM. A fingerstick blood sugar was performed but no laboratory work or x-rays were ordered. Patient #1 was discharged from the ED on 03/19/11 at 1547 to police custody. ED nursing staff documented Patient #1 was "more calm" at the time of discharge. There was no documentation in the medical record by ED Physician #1.

An interview with ED Physician #1 on 03/29/11 at 2:15 PM, revealed he did not perform a medical screening on Patient #1 on 03/19/11; he was only intervening with Patient #1's disruptive behavior.

A tour of the ED on 03/29/11 at 3:30 PM revealed there was a patient in the behavior health ED room. When standing in the hallway the patient could not be observed inside of the behavioral health ED room. Located at the nurse's station was the monitor screen for the behavioral health room. The picture was black and white. There was no ability to view any specifics about a patient such as skin color or the condition of the skin or the body.

An interview with ED Physician #2 on 03/29/11 at 3:35 PM, revealed the medical screening was "primarily a mental evaluation." He stated he did not review any of Patient #1's previous ED and/or hospital admissions. He stated initially there was no conversation with Patient #1 because it was "obviously pointless." He stated he could not ask Patient #1 any questions or do a formal evaluation. After the medication was administered and Patient #1 began calming down, he stated he looked in on Patient #1 but did not examine the patient. ED Physician #2 stated he felt Patient #1 was oriented and coherent. He stated that usually the ED Physician would screen a patient and then they would call behavioral health if the patient might need to be admitted. He felt Patient #1 was "clearly not suicidal." He stated he did not call Behavioral Health to assess because he felt that Patient #1 knew what he/she was saying. Additionally, if Patient #1 had not been in custody, he felt it might have been different because Patient #1 could not do anything in jail. ED Physician #2 stated he could hear Patient #1 from the hallway and other areas of the ED.

An interview with the Deputy Jailor on 03/30/11 at 11:45 AM, revealed Patient #1 was brought to the ED on 03/19/11 because he/she had been throwing food in the jail, washing his/her hair with toilet water, not sleeping, acting bizarre, talking out of his/her head making statements about being pregnant with twins, and talking about the devil. Jail personnel had been instructed by the County Attorney to take Patient #1 to the hospital for a mental health evaluation. On the ride to the hospital, Patient #1 was saying he/she was pregnant with twins and screaming and then would get quiet. The Deputy Jailor stated he did not observe the attending ED Physician (ED Physician #2) go into the room and examine or talk to Patient #1 anytime during the ED visit. After returning to the jail Patient #1 slept through the night. The next day Patient #1's behavior began escalating again. After the effects of the medication, that was administered in the ED, wore off Patient #1 began screaming out and talking about being pregnant. Patient #1 required tazing on 03/20/11 due to his/her behavior. On 03/21/11 Patient #1 was evaluated by a Mental Health Professional and Patient #1 was sent to a psychiatric hospital for admission.

An interview with the President of the contracted group of ED Physicians on 03/30/11 at 3:00 PM, revealed his typical emergency medical screening on a patient presenting with problems such as Patient #1, would include obtaining lab work, request Behavioral Health to evaluate, and then make a decision on the disposition of the patient.

An interview was conducted on 03/31/11 at 1:30 PM, with the Behavioral Health Registered Nurse, who was on-call on 03/19/11. She revealed she was not called to assess Patient #1 in the ED on 03/19/11.

An interview with the Chief of Staff of the ED on 03/31/11 at 2:05 PM, revealed every physician had a different routine of performing a medical screening of a patient with agitated behavior. He stated he would get information from the police and try to interview the patient. He usually obtained lab work to medically clear the patient and then got a psychiatric evaluation from Behavioral Health.

A review of the "History (Psychiatric-Medical Evaluation)" from the admitting psychiatric facility revealed Patient #1 was admitted as an inpatient on 03/21/11. The evaluation revealed Patient #1 was "exhibiting volatile behavior" and alternating between laughing inappropriately and crying. Patient #1 believed he/she was pregnant with twins and the father was a celebrity. Patient #1 was threatening and head banging causing severe bruising and black eyes. He/She was very agitated, psychotic, and manic. The patient had a history of "Bipolar 1 Disorder, Most Recent Episode Manic, With Psychotic Features, and Personality Disorder NOS." The admitting diagnostic impression was "Bipolar 1 disorder, most recent episode manic, severe with psychotic features, unspecified if mood-congruent psychotic features (principal)."

The facility failed to ensure an appropriate medical screening examination was conducted to determine if an emergency medical condition existed for Patient #1. Observations of the video the facility provided, record reviews and interviews revealed the attending ED Physician (ED Physician #2) was at Patient #1's ED doorway on two occasions for a total of 9 to 10 seconds. There was no conversation between ED Physician #2 and Patient #1 nor an examination. After Patient #1 had calmed down and was cooperative, ED Physician #2 still did not conduct a conversation or an examination of Patient #1 to determine the patient's mental status. The failure to conduct an adequate medical screening resulted in Patient #1 being returned to the jail and he/she required tazing after the effects of the medication wore off. Additionally, Patient #1 was admitted to a psychiatric facility on 03/21/11 in a psychotic state and had sustained severe bruising and black eyes from head banging. It was determined the facility's failure placed Patient #1 in imminent danger and at substantial risk of death or serious physical harm.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure that a patient presenting with an emergency medical condition, received an appropriate examination and treatment, that was within the capabilities of the facility, to stabilize a psychiatric condition for one patient (#1) in the selected sample of 21.

Findings include:

A video of Patient #1 taken on 03/19/11 in the Emergency Department (ED) was provided by the facility for surveyor review. The video encompassed the entire time Patient #1 was in the ED. Observations of the video revealed the following: Patient #1 entered the behavioral health room in the ED and sat down on the end of the stretcher. Patient #1's hands were cuffed and his/her legs were shackled. ED staff entered the room and obtained vital signs. Patient #1 could be observed with his/her mouth moving. ED nursing staff performed a nursing assessment. An ED Nurse Technician was present in the room with Patient #1 when Patient #1 came to a standing position and lunged toward the female staff. A facility Security Officer intervened. Patient #1's mouth was continually moving. Patient #1's assigned ED Physician (ED Physician #2) was observed for 36 seconds in the hall area outside of Patient #1's ED room. During the 36 seconds ED Physician #2 was talking with the Deputy Jailor in the hallway (not looking in the room where Patient #1 was located), then moved into the doorway where Patient #1 could be viewed for 4 seconds, and then he left the area. There was no conversation between ED Physician #2 and Patient #1 nor was an examination performed. Three ED nursing staff and a Security Officer entered Patient #1's room. Patient #1 stood up, leaned over the stretcher, and permitted the staff to administer two injections of medications in the buttocks area. Later after Patient #1 calmed down and was lying quietly on the stretcher, ED Physician #2 (attending physician) came to the doorway of Patient #1's ED room and looked into the room for 5 to 6 seconds and walked off. There was no conversation between Physician #2 and Patient #1 nor was an examination performed. ED Physician #2 did not come to the doorway or enter Patient #1's room at any other time while Patient #1 was in the ED. A meal tray was served to Patient #1. Patient #1 was calm and consumed his/her meal without any further incidents. Patient #1 was observed calmly walking out of the ED accompanied by the Deputy Jailor.

A review of Patient #1's ED medical record for 03/19/11 revealed he/she presented to the ED at 1437 accompanied by the police (from jail). The police had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was brought to the facility ED by order of the County Attorney. Review of the "Focused Nursing Assessment" revealed Patient #1 was agitated and cursing loudly. His/Her face was red from pepper spray. Patient #1 stated his/her skin was burning from the pepper spray. Review of Physician #2's documentation revealed Patient #1 was "very angry, combative, cursing, and yelling." Additionally, ED Physician #2 documented that Patient #1 was uncooperative for an exam, hostile, unable to determine orientation, normal motor and sensory response, normal inspection of neck and back, no respiratory distress, normal skin color, no rash, no signs of injury to the extremities. ED Physician #2 documented Patient #1 was on a 72 hour emergency hold due to danger to self and potentially violent. Patient #1's past history was "bipolar disorder." The clinical impression was "agitation" and the physician documented that he counseled Patient #1 on the diagnosis and need for follow-up. Review of the Medication Administration Record revealed that on 03/19/11 at 1450 Patient #1 received Geodon 20 mg intramuscular (IM) and Ativan 2 mg IM. A fingerstick blood sugar was performed but no laboratory work or x-rays were ordered. Patient #1 was discharged from the ED on 03/19/11 at 1547 to police custody. ED nursing staff documented Patient #1 was "more calm" at the time of discharge. There was no documentation in the medical record by ED Physician #1.

An interview with ED Physician #1 on 03/29/11 at 2:15 PM, revealed he did not perform a medical screening on Patient #1 on 03/19/11; he was only intervening with Patient #1's disruptive behavior.

An interview with ED Physician #2 on 03/29/11 at 3:35 PM, revealed the medical screening was "primarily a mental evaluation." He stated he did not review any of Patient #1's previous ED and/or hospital admissions. He stated initially there was no conversation with Patient #1 because it was "obviously pointless." He stated he could not ask Patient #1 any questions or do a formal evaluation. After the medication was administered and Patient #1 began calming down, he stated he looked in on Patient #1 but did not examine the patient. ED Physician #2 stated he felt Patient #1 was oriented and coherent. He stated that usually the ED Physician would screen a patient and then they would call behavioral health if the patient might need to be admitted. He felt Patient #1 was "clearly not suicidal." He stated he did not call Behavioral Health to assess because he felt that Patient #1 knew what he/she was saying. Additionally, if Patient #1 had not been in custody, he felt it might have been different because Patient #1 could not do anything in jail. ED Physician #2 stated he could hear Patient #1 from the hallway and other areas of the ED.

An interview was conducted on 03/31/11 at 1:30 PM, with the Behavioral Health Registered Nurse, who was on-call on 03/19/11. She revealed she was not called to assess Patient #1 in the ED on 03/19/11.

An interview with the Deputy Jailor on 03/30/11 at 11:45 AM, revealed Patient #1 was brought to the ED on 03/19/11 because he/she had been throwing food in the jail, washing his/her hair with toilet water, not sleeping, acting bizarre, talking out of his/her head making statements about being pregnant with twins, and talking about the devil. Jail personnel had been instructed by the County Attorney to take Patient #1 to the hospital for a mental health evaluation. On the ride to the hospital, Patient #1 was saying he/she was pregnant with twins and screaming and then would get quiet. The Deputy Jailor stated he did not observe the attending ED Physician (ED Physician #2) go into the room and examine or talk to Patient #1 anytime during the ED visit. After returning to the jail Patient #1 slept through the night. The next day Patient #1's behavior began escalating again. After the effects of the medication, that was administered in the ED, wore off Patient #1 began screaming out and talking about being pregnant. Patient #1 required tazing on 03/20/11 due to his/her behavior. On 03/21/11 Patient #1 was evaluated by a Mental Health Professional and Patient #1 was sent to a psychiatric hospital for admission.

The facility failed to provide further psychiatric examination, treatment, and stabilization for Patient #1 on 03/19/11. Although, the facility had available a Behavioral Health Access team they were not contacted to evaluate Patient #1. Patient #1 was administered antipsychotic medications and after calming down no further psychiatric evaluation was conducted or arranged for. There was no definitive psychiatric follow-up arranged, prior to discharging Patient #1 back to jail.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure one patient (#1) in the selected sample of 21 received an appropriate medical screening examination within the capability of the hospital's emergency department (ED). The facility failed to follow their policies "EMTALA - Emergency Medical Treatment" and "Transfer/Receiving Patients According to COBRA" resulting in Patient #1 not receiving an appropriate medical screening to determine if an emergency medical condition existed. Findings include:

Review of the facility policy "Transfer/Receiving Patients According to COBRA" revealed "Every person presenting to the Emergency Department shall receive an appropriate medical screening examination. This examination must be sufficient to determine if the person has an emergency medical condition." Review of the facility policy "EMTALA - Emergency Medical Treatment" revealed "the initial medical screening examination must be conducted by qualified medical personnel to determine with reasonable confidence whether an emergency medical condition exists. The medical screening examination should be an ongoing process accompanied by a record that reflects continuous monitoring of the patient. An emergency medical condition is a condition whose acute symptoms are severe enough that without immediate medical attention, it is expected to jeopardize the health of the individual, seriously impair bodily function, or cause serious dysfunction of any organ or body part. Symptoms include pain, psychiatric disturbances, and substance abuse."

A review of the medical staff rules and regulations revealed the "EMTALA related medical screening examination" could be performed by the following: The ED Physicians, the ED Physician's Assistants, and the ED Advanced Registered Nurse Practitioners. Additionally, the obstetric nurses were authorized to perform the medical screening examination for pregnant patients at 20 weeks or greater gestation.

A video of Patient #1 taken on 03/19/11 in the Emergency Department (ED) was provided by the facility for surveyor review. Review of the video revealed it did not contain audio nor was there the ability to know what time events took place. There was a minute and second counter on the video. The video encompassed the entire time Patient #1 was in the ED. Observations of the video revealed the following: Patient #1 entered the behavioral health room in the ED and sat down on the end of the stretcher. Patient #1's hands were cuffed and his/her legs were shackled. Outside of the room was a Deputy Jailor and a facility Security Officer. ED staff entered the room and obtained vital signs. Patient #1 could be observed with his/her mouth moving. ED nursing staff performed a nursing assessment. An ED Nurse Technician was present in the room with Patient #1 when Patient #1 came to a standing position and lunged toward the female staff. A facility Security Officer intervened. Patient #1's mouth was continually moving. Patient #1's assigned ED Physician (ED Physician #2) was observed for 36 seconds in the hall area outside of Patient #1's ED room. During the 36 seconds ED Physician #2 was talking with the Deputy Jailor in the hallway (not looking in the room where Patient #1 was located), then moved into the doorway where Patient #1 could be viewed for 4 seconds, and then he left the area. There was no conversation between ED Physician #2 and Patient #1 nor was an examination performed. Three ED nursing staff and a Security Officer entered Patient #1's room. Patient #1 stood up, leaned over the stretcher, and permitted the staff to administer two injections of medications in the buttocks area. Another ED physician (Physician #1), who was not treating or involved in Patient #1's care, entered Patient #1's room, 1.5 minutes after the medications were administered. ED Physician #1 was observed rushing into the room and making statements to Patient #1, while raising his arm and pointing his finger at Patient #1. ED Physician #1 started to leave the room when Patient #1 said something. Physician #1 abruptly turned around and went back toward Patient #1. ED Physician #1 placed his left hand on Patient #1's neck and upper chest area and pushed Patient #1 down on the stretcher. ED Physician #1 left Patient #1's ED room and did not return while Patient #1 was in the ED. Later after Patient #1 calmed down and was lying quietly on the stretcher, ED Physician #2 (attending physician) came to the doorway of Patient #1's ED room and looked into the room for 5 to 6 seconds and walked off. There was no conversation between Physician #2 and Patient #1 nor was an examination performed. ED Physician #2 did not come to the doorway or enter Patient #1's room at any other time while Patient #1 was in the ED. A meal tray was served to Patient #1. Patient #1 was calm and consumed his/her meal tray without any further incidents. Patient #1 was observed calmly walking out of the ED accompanied by the Deputy Jailor.

A review of the history of Patient #1's visits to the facility's ED and admissions to the facility revealed Patient #1 had been admitted to the facility's psychiatric unit on 03/23/09 through 04/01/09 with the diagnosis of "Psychosis." Patient #1 had been experiencing auditory hallucinations (hearing voices).

A review of Patient #1's ED medical record for 03/19/11 revealed he/she presented to the ED at 1437 accompanied by the police (from jail). The police had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was brought to the facility ED by order of the County Attorney. Review of the "Focused Nursing Assessment" revealed Patient #1 was agitated and cursing loudly. His/Her face was red from pepper spray. Patient #1 stated his/her skin was burning from the pepper spray. Review of Physician #2's documentation revealed Patient #1 was "very angry, combative, cursing, and yelling." Additionally, ED Physician #2 documented that Patient #1 was uncooperative for an exam, hostile, unable to determine orientation, normal motor and sensory response, normal inspection of neck and back, no respiratory distress, normal skin color, no rash, no signs of injury to the extremities. ED Physician #2 documented Patient #1 was on a 72 hour emergency hold due to danger to self and potentially violent. Patient #1's past history was "bipolar disorder." The clinical impression was "agitation" and the physician documented that he counseled Patient #1 on the diagnosis and need for follow-up. Review of the Medication Administration Record revealed that on 03/19/11 at 1450 Patient #1 received Geodon 20 mg intramuscular (IM) and Ativan 2 mg IM. A fingerstick blood sugar was performed but no laboratory work or x-rays were ordered. Patient #1 was discharged from the ED on 03/19/11 at 1547 to police custody. ED nursing staff documented Patient #1 was "more calm" at the time of discharge. There was no documentation in the medical record by ED Physician #1.

An interview with ED Physician #1 on 03/29/11 at 2:15 PM, revealed he did not perform a medical screening on Patient #1 on 03/19/11; he was only intervening with Patient #1's disruptive behavior.

A tour of the ED on 03/29/11 at 3:30 PM revealed there was a patient in the behavior health ED room. When standing in the hallway the patient could not be observed inside of the behavioral health ED room. Located at the nurse's station was the monitor screen for the behavioral health room. The picture was black and white. There was no ability to view any specifics about a patient such as skin color or the condition of the skin or the body.

An interview with ED Physician #2 on 03/29/11 at 3:35 PM, revealed the medical screening was "primarily a mental evaluation." He stated he did not review any of Patient #1's previous ED and/or hospital admissions. He stated initially there was no conversation with Patient #1 because it was "obviously pointless." He stated he could not ask Patient #1 any questions or do