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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements for Medical Screening Examination, citing

1 of 20 patients (Patient #2) that presented to the emergency department (ED) in need of a psychiatric evaluation and the hospital failed to keep the patient safe until the psychiatric evaluation could be achieved to determine if inpatient psychiatric care was required.

Patient #2 on 12/13/2023 arrival to 12/14/2023 elopement, drove off in an unattended, running ambulance with another patient loaded in the back.

Cross Reference to Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination

Based on record review and interview, the hospital failed to ensure each patient received an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, citing

1 of 20 patients (Patient #2) that presented to the emergency department (ED) in need of a psychiatric evaluation and the hospital failed to keep the patient safe until the psychiatric evaluation could be achieved to determine if inpatient psychiatric care was required.

Patient #2 on 12/13/2023 arrival to 12/14/2023 elopement; drove off in an unattended, running ambulance with another patient loaded in the back.

Findings

Patient #2 Arrived 12/13/2023 and Eloped 12/14/2023
On 12/13/2023 at 6:05 PM, Patient #2 arrived via ambulance under an EDO (Emergency Detention Order) No. 23-240854 at 6:07 PM for walking on Dallas North Tollway, intentionally trying to get hit, and jumping on moving vehicles.

Patient #2's MSE was started on 12/13/2023 at 6:28 PM by Physician #15 reflected the patient's agitated and altered state.

The 12/13/2023 MSE (first physician) reflected, "38 y.o. (year old) male with PMHx (Previous Medical History) of asthma, meth-use who comes to the ED (emergency department) as APOWW (Apprehension by Police Officer Without Warrant/Emergency Detention Order) today. Associated sx (symptoms) of AMS (Altered Mental Status). Police reports that pt was found walking in the Dallas north tollway...Physician Exam...Neurological: General: No focal deficit present. Mental Status: He is disoriented. Cranial Nerves: No cranial nerve deficit. Comments: Oriented x1 Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal...Lab results (included) Positive Amphetamines...Medical Decision-Making Problems Addressed: Psychosis, unspecified psychosis type: complicated acute illness or injury...Substance abuse: complicated acute illness or injury...Differential Diagnosis: Suicide ideation, homicidal ideation, acute psychosis, hallucinations, intoxication, and overdose.

The ED physician does not document if the pt has suicide or homicide ideation. There are no history questions regarding delusions, hallucinations, judgment, or insight.

The Physician orders included Geodon, Lab work, Sitter, and BHA (Behavioral Health Assessment/Psychiatric Evaluation). Geodon was given at 7:09 PM due to his agitated state on admission. Patient #2 attempted to elope multiple times. There was no elopement risk assessment completed.

The initial (first nurse) Nurse Documentation on 12/13/2023 described the patient as, "confused, agitated, impulsive, apprehensive, irritable, restless, combative, unable to verbalize (emotional state)" and "patient behaviors: threatening, uncooperative, non-compliant, not participating in care, and aggressive verbally." "Suicide Screening" was documented as all "no" answers which resulted in No risk (CSSR/Columbia suicide screen not listed as high-risk).

The post Geodon (second nurse) Nurse reassessment at 11:30 PM reflected, "Pt is awake and calm and cooperative. Pt is laying in bed. Pt denies any si/hi (Suicide/homicide) at this time and has agreed to talk with the assessor...11:45 PM Pt at first would not talk to the assessor. Pt then started to mumble and no (sp: not) talk clear to the assessor and so they stated that they would call back...(12/14/2023) 12:00 AM/Midnight The patient got out of bed, and I called for the officer in the ER. The patient then started to proceed to the ER bay and walk out. The ER officer and I got the patient redirected and agreed to come back into his room to be assessed...12:15 AM Pt started to get agitated and attempting to redirect pt at this time. Trying to get a hold of the assessor to reassess pt...12:21 AM Security called to patient's bedside (again)...12:30 AM Security and er officer trying to deescalate the pt..."

There was no physician notification of the patient's heighten agitation for additional medication.

The Behavioral Health Assessment/Psychiatric Evaluation was not completed.

On 12/14/2023 at 2:40 AM, Patient #2 was able to elope after breaking down the ambulance bay doors, and drove off in an unattended, running ambulance with another patient loaded in the back. Plano PD (Police Department) safely apprehended Patient #2.

The 12/14/2023 Physician (second physician) post elopement documentation reflected, "Rechecks/Consults: ED Course 12:47 AM Patient apparently ran out of ED, stole an ambulance from the bay that had a 93yo F discharged in it. He reportedly took off with ambulance with patient in the back. More to follow. 1:09 AM Reportedly (named patient) is now in custody of police. The 93yo F (year old Female) patient in back of ambulance is reportedly unharmed. Unclear disposition of both patients. 2:34 AM: Patient reportedly in PD (Police Department) custody. He is going to need further psychiatric evaluation at some point, though he is not appropriate for our facility at this time."

During record review and interview on 4/04/2024 at 10:45 AM, Personnel #4 and #5 were present. Personnel #4 reviewed that there had been no previous care or visit for this patient...They were asked about elopement risk. Personnel #4 stated the ED doesn't do an elopement risk. No elopement screening was completed. A nurse could enter information in their notes...Personnel #4 stated we have to do everything in our power to keep him safe. They were asked if precautions were implemented. Personnel #4 stated no, it does not appear so, because SI (suicide) risk was low. No order for monitoring. No order for safety sitter because it is a nursing judgement. They were asked if a Sitter is required to complete documentation. Personnel #4 stated no, only if it was a Psych 1:1 sitter. They were asked if a Monitoring order was placed. Personnel #4 stated there was no order for monitoring by the MD...They were asked if the Behavioral Assessment (BHA) was ordered and completed. Personnel #4 stated ordered at 10:51 PM but not completed. Several attempts were made to complete the BHA, but the patient was not able at 11:52 PM not cooperative/not answering question.

During a tour of the Emergency Department on 4/04/2024 at 1:37 PM, Personnel #1 and #6 were present. The videos were reviewed (see below)...Personnel #6 stated we have had multiple patients crash/break through the door to exit/elope through the ambulance entry. Personnel #6 stated there was not a safety switch for the ambulance bay door like the safety switch for exiting to the lobby. The 2 (saved) videos were viewed prior to the tour. The videos were of the ambulance bay that showed the patient at a full sprint to the running ambulance and driving off. The crew was unaware and loading a patient. One behind, male EMT and one on side door, female. The female was in the side door and backing out. While backing out she looked into the cab area like she saw or heard something. Then she exited the van and closed the door. She moved to the passenger side window looking into it as the ambulance drove off. The male attendant ran back to the back door in time to open the door. The door was ajar when the van left. No other videos were kept.

During a telephone interview on 4/05/2024 at 11:30 AM, Personnel #9 (oncoming/2nd ED Physician) was asked about the patient. Personnel #9 stated, "I was tertiarily to his care. I did not see him. Personnel #15 (outgoing ED Physician) assessed him and directed his care. I took report. Normally that is around 11:30 to midnight. The (ED Provider) note is Personnel #15's and the Recheck notes are mine. I was not a party to or informed of what occurred with the patient leaving until after the fact...I was in what we call the Doc box, a common area to chart. I started to hear a commotion. He ran out and police ensued...From the documentation, he was on a Meth bender, there was a struggle with authorities, and he came in with an APOWW. He got Geodon, came to, and bolted. They were waiting on him to wake up after Geodon to do the BHA. At almost 11 o'clock the Behavioral Health Assessor attempted to do the BHA and wasn't able to get him to participate." Personnel #9 was asked how an APOWW patient is handled. Personnel #9 stated, "normally there is a behavioral health sitter with them and an officer in the area as well. They take the belongings and have them wear green paper scrubs." Personnel #9 was asked if the patient should be pacing in the hallway versus in the ED room. Personnel #9 stated, "pacing in the hallway is not normal. That would be a pretty big deal and I would want to be aware of that. I would deal with de-escalation for that. Every patient is different. They could be jonesing or sizing up if they could make it out. I did not see that happening and was not notified of that."

During a telephone interview on 4/05/2024 at 2:20 PM, Personnel #7 stated, "I have worked for the hospital for about 2 years when I am off duty at the Department." Personnel #7 was asked about the patient situation. Personnel #7 stated, "I was told he was on an APOWW which means once the hospital accepts them, he can't leave until the hospital evaluates him and tells him he can leave. APOWW patients are to be prevented from leaving." Personnel #7 was asked if the patient was in green paper scrubs. Personnel #7 stated, "I am pretty sure he was in his own clothes."

During a telephone interview on 4/05/2024 at 6:00 PM, Personnel #8 was asked her understanding of an APOWW. Personnel #8 stated, "obviously the legal ability to hold the patient." Personnel #8 was asked if that included the duty to keep him safe. Personnel #8 stated, "yes." Personnel #8 was asked what the Keep me safe checklist was and entailed. Personnel #8 stated, "the check and balance for the room made safe for Psych patient." Personnel #8 was asked if normally they take belongings, give paper scrubs, etc. Personnel #8 stated, "typically yes. So, this patient did not screen high risk for suicide. So, no paper scrubs. After several hours then I woke him to assess him. At that time, he was talking to me. He did not remember what happened prior that brought him in. I started to build rapport with him. I attempted to have him complete his Behavioral Health Assessment, but he was mumbling. I encourage him to speak to them, but the assessor decided he was not able." Personnel #8 was asked not able functionally. Personnel #8 stated, "yes ma'am. I attempted again later after reorienting him to the process. I was trying to get the assessor on the phone and that was when he took off." Personnel #8 was asked if he was agitated at that time. Personnel #8 stated, "he was in the doorway, anxious, and wanting to get it all over with. He was starting to escalate. The police officer was with me and redirect/de-escalate him. Security came as well." Personnel #8 was asked if she notified the physician and asked for medication for the agitation. Personnel #8 stated, "it happened very quickly. I was on phone at the same time. I didn't have 15 minutes to escalate. I had been able to redirect him. I did not think he would run."

During an interview and record review on 4/08/2024 at 8:50 AM, Personnel #6 was asked about the 3 psychiatric patients and the use of the green paper scrubs. Personnel #6 stated, "I don't think any of them had the paper scrubs on, only their cloths."

The facility's internal investigation did not interview the sitter, identify use or non-use of environmental controls (green paper scrubs, elopement risk assessment, and precautions) or evaluate the need for further medication for increased agitation (notify physician/missed opportunity).

The hospital's 10/07/2022 last reviewed "Medical Screening Examinations and Patient Transfers" policy required, "shall receive an appropriate Medical Screening Examination...including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition...The physician will determine if an Emergency Medical Condition exits and if so, initiate necessary stabilizing treatment or arrange for a transfer to another hospital as appropriate.