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Based on interview and record review, the facility failed to provide an appropriate medical screening exam to one of 22 sampled patients (Patient 1) who expressed suicidal ideation (thoughts of wanting to kill one's self) when Emergency Department (ED) staff escorted Patient 1 off hospital property before he received a mental health assessment.

This failure resulted in Patient 1 not receiving an appropriate screening exam to rule out an emergent medical condition and increased the potential of Patient 1 acting on his suicidal ideation and ending his own life.

Findings:

Review of Patient 1's medical record revealed the following:

A document titled "ED Complete Triage RFV," dated 3/26/15, by a Registered Nurse (RN), indicated Patient 1 arrived to the ED at 10:52 a.m. by ambulance with a chief complaint of all over body cramping. The RN wrote Patient 1 had a history of mental illness and denied thoughts of harming himself or others at that time. The document indicated "Tracking Acuity: 2 - Emergent" (A facility policy and procedure titled, "Emergency Department Assessment, Reassessment and Documentation," origination date 6/18/09, indicated "Level 2 EMERGENT - Conditions that are a potential threat to life, limb, or function. Requires rapid medical intervention or delegated acts.").

An ED physician note dated 3/26/15, indicated the provider made initial contact with Patient 1 at 10:58 a.m. The provider's note indicated Patient 1 had a history of mental illness, which included anxiety, bipolar disorder, attention deficit disorder, and post-traumatic stress disorder. The provider ordered a medication for anxiety, a medication for pain, and labs.

A nursing note dated 3/26/15, at 11:13 a.m., indicated staff escorted Patient 1 to the ED lobby to wait for a lab draw after Patient 1 yelled at and made a derogatory hand gesture to a nurse.

A nursing note dated 3/26/15, at 12:03 p.m., indicated, "Events: pt [patient] called pd [police department] claiming SI [suicidal ideation]; denies at present."

A physician reexamination note dated 3/26/15, at 1:48 p.m., indicated, "Assessment: I assumed care of this patient from the RME [rapid medical exam] provider. Patient now expressing suicidal ideation. Therefore, will order for psych workup at this time."

A nursing note dated 3/26/15, at 1:49 p.m., indicated "Events: pt to triage with provider states "I want to kill myself."

A physician order dated 3/26/15, at 1:51 p.m., indicated, "Consult to Mental Health (Mental Health Consult)."

A nursing note dated 3/26/15, at 1:54 p.m., indicated, "Events: pt placed in fron t (sic) of security in wheelchair. charge RNs aware of pt statement."

A nursing note dated 3/26/15, at 2:01 p.m., indicated, "Events: pt frequently causing a disturbance in lobby-standing up pretending that he is going to fall-verbal altercations with security."

A physician order dated 3/26/15, at 2:11 p.m., indicated, "haloperidol (Haldol) [an anti-psychotic medication]...Order Details: 10 mg [milligram, a unit of measurement], IM [intra muscular], INJ [injection], q4hr [every 4 hours] STAT [immediately] PRN
[as needed] Agitation..."

A nursing note dated 3/26/15, at 2:19 p.m., indicated, "Code Gray [facility alert of a combative or violent patient in the hospital requiring security personnel assistance] called to ED Lobby regarding [Patient 1]. RN out to assist. Pt yelling and threatening staff while being restrained by several security guards/staff members. Pt wheeled in wheel chair to amb [ambulance] bay with security, pt yelling at this RN...pt instructed several times to stop yelling/stop yelling at staff when pt continued to yell ...Pt escorted off property by security after no psychiatric hold exists for this pt. Charge RN aware."

An ED Discharge Note dated 3/26/15, at 2:51 p.m., indicated, "Discharge Disposition: Left after medical screening exam."

Review of Patient 1's medication administration record for 3/26/15, indicated no documented evidence Patient 1 received haloperidol as ordered for his agitation. Review of provider and nursing notes indicated no documented evidence Patient 1 received a mental health consult.

During an interview with the ED Medical Director (EDMD) on 7/20/21, at 8:40 a.m., the EDMD was asked to describe the role and responsibility of the ED provider when a patient expressed suicidal ideation during the course of their stay in the ED. The EDMD stated the ED provider would talk to the patient as soon as possible, order medical clearance labs, call the social worker to do a mental health assessment, and place an order for staff supervision of the patient to maintain his or her safety. The EDMD stated the provider would try to have a patient in the ED lobby moved to a room or chair inside the ED. The EDMD stated, in 2015, the ED providers diverted to the social workers to do the mental health assessments to make the determination to hold a patient in custody for 72 hours or recommend they be discharged home with instructions on how to access mental health resources in the community. The EDMD stated, when a suicidal patient in the ED lobby became violent, the staff would restrain the patient, the ED provider would order a medication to subdue the agitated patient, and the staff would place the patient in a private room. The EDMD stated, once Patient 1 made a statement of suicidal ideation, he should have received the mental health consultation by the social worker to complete the medical screening exam.

During a concurrent interview and record review with the ED Nursing Director (EDND) on 7/20/21, at 9:50 a.m., the EDND reviewed Patient 1's medical record of his visit to the ED on 3/26/15. When asked if Patient 1 should have remained in the lobby after he expressed suicidal ideation, the EDND stated, staff should have tried to move the patient to a PIT chair (provider in triage, chairs located inside the ED next to the triage provider) with a security officer. The EDND verified Patient 1's medical record indicated that when Patient 1's behavior became disruptive in the lobby, staff initiated a Code Gray, which resulted in security officers wheeling Patient 1 to the ambulance bay in his wheelchair. The EDND stated it appeared that shortly thereafter the ED provider ordered a medication to reduce Patient 1's agitation, however, Patient 1 did not receive the medication. The EDND confirmed the nurse in charge instead made the determination to allow the security officers to escort the patient off hospital property. The EDND stated, the ED staff should have attempted to de-escalate Patient 1's agitation and bring him back to the ED to a location with less stimulation. The EDND stated, ideally, the ED staff should have restrained Patient 1 to medicate him, which would have allowed Patient 1 to eventually received the mental health consultation. The EDND, after reviewing the nursing notes, stated the nurse in charge made the decision to have the security officers escort Patient 1 off the hospital property before he received his mental health assessment by a social worker, and therefore, he did not receive a complete medical screening exam to rule out an emergency medical condition.

During an interview with the Physician Assistant (PA) on 7/27/21, at 10:20 a.m., the PA stated he had taken over as Patient 1's provider after the critical care medical doctor did the initial rapid medical exam. The PA stated he did consider Patient 1's SI as a potential emergency medical condition that would require stabilization, and confirmed he ordered a mental health consult. The PA stated he did not believe he had seen the patient yet and did not know the reason for staff initiating a code gray for Patient 1. The PA stated staff should have consulted with him first before escorting Patient 1 off hospital [property]. The PA stated he could have tried to de-escalate the patient. The PA stated, "That would have been the appropriate thing to do."

Review of a facility policy titled "[Name of facility] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 1/1/16, indicated, "Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Medical Screening Examination means the process of examination and evaluation of the individual required to determine, within the capabilities (services and staff) if an individual who comes to the Emergency Department has an Emergency Medical Condition...The Medical Screening Examination is an ongoing process, including monitoring of the individual, until the individual is either Stabilized or Transferred."

Review of a facility policy titled "Managing, Assessing, and Protecting Patients Considered being a Danger to Themselves or Others, or who are Gravely Disabled," origination date 6/11, indicated, "When the assessment indicates a risk of suicide...A referral is made to Clinical Social Services or the mental health clinician, for the evaluation of a patient who presents after suicide attempt or is assessed to be at risk for suicide. The clinical social worker/mental health clinician will...Collaborate with the nursing staff and initiate a plan of care to protect the patient from self-harm...In order to rule out medical etiology for the psychiatric presenting symptoms, evaluation is completed after medical clearance has been obtained...Complete a behavioral/mental health assessment and reassess PRN if changes in patient condition...Facilitate consultation with mental health providers...If the patient meets the criteria for a 5150 application...Write a 5150 application...The RN will provide a safe and secure environment with the assistance of the safety attendant...Document in the EHR [electronic health record] and notify the physician of any of the following...Sudden behavior changes...Anxiety/agitation...Aggressive or self-injurious behaviors...."