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Based on interview, record review and policy review, the hospital failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of a psychiatric Emergency Medical Condition (EMC) within its capacity and capability, for one individual (patient # 12) and appropriate treatment to stabilize the emergency medical condition of two individuals (patients # 25 and 26) of 30 patients' Emergency Department (ED) records reviewed from February 2017 through July 2017. These failures have the potential to affect all patients who present to the ED seeking care. The ED sees approximately 5,310 patients per month. The facility census was 219.

Please refer to A2406 and A2407 for details.



18018

Based on interview, record review and policy review, the hospital failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of a psychiatric Emergency Medical Condition (EMC) within its capacity and capability, for one patient (#12) out of 30 patients' Emergency Department (ED) records reviewed. These failures had the potential to affect all patients who presented to the ED. The facility's ED average monthly census over the past six months was 5,310.

Findings included:

1. Review of the facility's policy titled, "EMTALA - Medical Screening Examination and Stabilization Policy," dated 02/01/16, showed that a hospital must provide an appropriate MSE which includes ancillary services and on-call physicians, to all individuals presenting to the ED. The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists. The psychiatric MSE is to determine if the psychiatric symptoms have a physiologic etiology and includes an assessment of suicidal or homicidal thoughts or gestures that indicate danger to self or others. The ED physician shall consult the psychiatric qualified medical professional (QMP) providing the behavioral assessment, but shall remain the primary decision-maker with regard to transfer and discharge of any individual presenting with psychiatric behavioral emergencies.

2. Review of the facility's policy titled, "Suicidal Patient Screening and Management," showed the following screening risk factors for all patients presenting for admission for risk of suicide:
- Current or recent thoughts of suicide;
- Recent or past history of suicide attempts within the past year;
- Evidence of suicidal planning or intent;
- Injury consistent with attempts to cause self-harm;
- Evidence of a very stressful event that occurred in the past several weeks leading to patient actions that could lead to self-harm;
- Alcohol and/or drug and/or over the counter drug overdose;
- Severely depressed mood;
- Psychotic episode;
- Eating disorder;
- Anxiety/panic attack; and
- Post Traumatic Stress Disorder (PTSD).

3. Review of Patient #12's H&P in the ED medical record showed the following:

- The patient arrived at the ED on 05/01/17 at 4:38 PM by ambulance escorted by police for an attempted suicide by drug overdose and suicide ideation.
- The patient stated that she took 40 tablets of 300 milligrams of Gabapentin (used to treat seizures and pain) at home, one hour before she was arrested for outstanding warrants. The police department called the ambulance.
- The physical exam showed that the patient had anxiety, labs were normal and poison control stated that the patient was not in the toxic range for Gabapentin.
- The patient was placed on suicide precautions.
- While on precautions, the patient tried to harm herself by slapping herself in the face and slapping her head. At this time the patient was placed in restraints.
- The patient was evaluated by Staff O, Mental Health Assessor, on 05/01/17 at 7:05 PM and determined that the patient could be discharged back to police custody on suicide watch.
- The documentation showed that the patient was discharged on 05/01/17 at 6:10 PM to police custody.

Review of the "Pre-Hospital Care Report," dated 05/01/17 showed:

- On arrival to the jail, the patient was sitting upright on a bench.
- The patient stated that just before she was arrested she took a handful of Gabapentin tablets with the intent to harm herself.
- The patient stated that she was depressed and has had a difficult time with life.
- The patient stated, "I have been without my psychiatric medications for a month and I don't see the point in taking them."
- The patient stated that she was suicidal.

Review of the Behavioral Health Assessment, via telemedicine, dated 05/01/17 at 5:29 PM showed that Staff O, Mental Health Assessor documented the following:

- The patient was a 38 year old female that had been arrested for failure to appear for outstanding warrants.
- The patient took a handful of Gabapentin tablets prior to the police arrival.
- The patient stated, "My boyfriend beat me," and "I feel lost."
- The patient stated that her sister kicked her out and she had been homeless for a month.
- She stated that she felt hopeless, helpless, worthless and had racing thoughts with crying spells.
- The patient was unemployed with no income.
- The patient had a history of bipolar, previous psychiatric hospital admission in 02/2017, hypertension, migraines, PTSD (raped at age 14 and at age 33) and brother completed suicide in 2014.
- The patient continued to have suicidal ideations and stated that she will take care of herself once she was released from the police.
- The patient had insomnia.
- The patient stated that she felt like everyone was watching her.
- Staff P recommended that the patient go back to jail and be placed on suicide watch.

Review of the patient's observation flow sheet dated 05/01/17 at 4:45 PM showed that the patient had been lying in bed, quiet and withdrawn during her time in the ED.

During an interview on 07/27/17 at 1:10 PM, Staff P, ED Registered Nurse, stated that the patient was angry about being watched and lashed out at her. She stated that she felt ok with the decision to send her back to jail.

During an interview on 07/27/17 at 2:03 PM, Staff Q, ED Physician, stated that the Mental Health Assessor documented after the patient was discharged and if she had the details of the patient's history, she would have reassessed the patient and possibly considered an inpatient psychiatric facility.

The facility failed to perform an appropriate psychiatric MSE and recognize that Patient #12 presented with several risk factors for self harm. The patient also tried to harm herself during her ED visit.

4. During an interview on 07/26/17 at 9:20 AM, Staff A, Chief Nursing Officer (CNO), stated that if the physician did not agree with the mental health assessor's evaluation of the patient, they should have requested another evaluation or placed a call directly to the psychiatrist.

5. During an interview on 08/03/17 at 3:34 PM, Staff R, ED Medical Director, stated that he was unaware that the Mental Health Assessors had the impression that a police hold meant they couldn't be admitted and that maybe the physicians put too much weight on what the Mental Health Assessors have said. He also stated that he felt that it was best to err on the side of caution and they should have been admitted if they were actively suicidal.

The facility failed to complete an MSE sufficient to determine the presence of a psychiatric emergency prior to discharging Patient #12 to police custody. This placed Patient #12 and all patients expressing suicidal thoughts at risk for further injury or death.














18018

Based on record review and interview, the facility failed to stabilize an Emergency Medical Condition (EMC) for two patients (#26 and #25) out of 30 patients that presented to the facility's Emergency Department (ED) seeking care for either an emergency medical condition or psychiatric condition out of a sample selected from the past six months. These failures had the potential to affect all patients that presented to the ED. The facility's average monthly ED visits over the past six months was 5,310.

Findings included:

Review of the facility's policy titled, "EMTALA - Medical Screening Examination and Stabilization Policy," dated 02/01/16, showed the following directives for staff:

Stabilizing Treatment Within Hospital Capability:
The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED (Dedicated Emergency Department) has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/herself or others.

Stable:
The physician or QMP (Qualified Medical Professional) providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist.

Stabilizing Treatment Within Hospital Capability and Transfer:
Once the hospital has provided an appropriate MSE (Medical Screening Exam) and stabilizing treatment within its capability, an appropriate transfer may be effected by following the appropriate transfer provisions.

Review of Patient #26's history and physical (H&P) in the medical record showed the following:

- The patient arrived at the ED on 03/16/17 at 9:32 PM by ambulance from the police station for attempted suicide by strangulation.
- The staff at the jail found the patient with her bra strap wrapped around her neck, unresponsive and blue in the face.
- The patient stated that she was trying to kill herself because she didn't want to live anymore.
- The patient has had multiple past suicide attempts.
- The physical exam performed by Staff K, ED physician, documented that the patient's neck had swelling anteriorly with two separate sets of ligature markings.
- The psychiatric exam showed that the patient had flat affect, depressed mood and active suicidal ideation.
- The CT scan (a series of x-ray images taken from different angles) of the neck was negative.
- The patient was discharged back to police custody on 03/16/17 at 11:54 PM.

Review of the "Pre-Hospital Care Report," dated 03/16/17 showed:

- On arrival to the jail, the patient was lying on a cot.
- The patient's eyes were minimally responsive to verbal, but responded to a sternal rub.
- The staff told the medics that the patient had started to breathe again when they removed the bra strap from around her neck.
- The patient had a hoarse voice, difficulty speaking, sore throat, head pain and abdominal pain.
- The patient had redness around her mid neck.

Review of an affidavit dated 03/16/17, completed by Staff S, Police Officer (the first person to find the patient) stated:

- Patient #26 was found alone in a jail cell with her jail issued shirt and bra strap wrapped around her neck.
- She was blue in appearance and not breathing.
- Once the clothing was removed from her neck, she slowly began to recover.

Review of the ED's continuous observation flowsheet showed that the patient was placed on suicide precautions and was lying in bed crying at the time of arrival.

Review of Patient #26's Behavioral Health Assessment, via telemedicine, dated 03/16/17 at 11:10 PM, showed that Staff E, Mental Health Assessor's documented the following:

- The patient had been incarcerated (in jail) for fines for two days of a five day stay;
- The patient had suicide ideations for the past three weeks;
- The patient attempted suicide by strangulation with her bra;
- The patient had previous suicide attempts in 09/2016 and another in 2010;
- The patient had not been receiving any outpatient treatment;
- The patient had a history of anxiety disorder, PTSD (rape, molestation and physical abuse), sleep disorder, bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), seizure disorder, agoraphobia (the fear of being in situations where escape might be difficult) and depression;
- The patient had not been eating and was giving her food away in jail;
- The patient was depressed with a flat affect;
- Staff E spoke with Staff S, Police Officer, and he stated that Patient #26 was not being released from custody;
- Staff E spoke with Staff K, ED physician and agreed that the patient should go back to jail on 24 hour suicide watch instead of a psychiatric admission.

During an interview on 07/27/17 at 7:45 AM, Staff G, Patient Care Technician/Sitter, stated that the patient's neck was red with some bruising.

During an interview on 07/26/17 at 3:40 PM, Staff E, Mental Health Assessor, stated that:

- Patient #26 was not released from police custody.
- Her supervisors had told her not to recommend inpatient treatment if the patient was on a police hold.
- After the behavioral health assessment, she spoke with Staff K, ED physician and agreed on sending Patient #26 back to jail on a 24 hour suicide watch.
- If the physician disagreed with her recommendation, then she would have proceeded with whatever the physician decided.
- The physician weighed heavily on her behavioral health assessment when he made his decision.
- Staff E was unaware that the physician could override the police officer.
- If a patient actively tried to commit suicide this would have been criteria for an inpatient facility recommendation.

During an interview on 07/27/17 at 9:30 AM, Staff K, ED Physician, stated that he thought that Patient #26 was just trying to get out of jail. He also stated that you couldn't hang yourself with a bra strap.

Review of the police report dated 03/17/17 showed that after Patient #26 was discharged back to jail she continued to state that she didn't want to live any longer and would kill herself as soon as they let her go. The police department continued to arrange placement at a psychiatric hospital.

The facility failed to stabilize Patient #26 and recognize that the patient was suicidal and a psychiatric emergency that needed inpatient care, placing the patient at risk for further injury or death.

Review of Patient #25's history and physical (H&P) in the medical record showed the following:

- The patient arrived to the ED on 03/24/17 at 3:30 PM escorted by police for a suicide attempt, suicidal ideation and violent behavior.
- The patient had superficial lacerations to both forearms and several scars from previous cutting.
- The patient's parents contacted the police because the patient told them he was going to kill himself with a knife.
- When the police arrived at the home, the patient was in the front yard waving a knife at the police officers and yelled, "I am going to make you shoot me."
- The patient told police officers that he wanted to kill himself.
- The police restrained the patient and brought him in to the ED.
- The physical exam performed by Staff K, ED Physician, showed that the patient had several new lacerations and had no homicidal ideations.
- Labs were negative for alcohol and drugs.
- The patient was discharged to police custody on 03/24/17 at 5:29 PM.

Review of Patient #25's Behavioral Health Assessment, via telemedicine, dated 03/24/17 at 5:49 PM showed the following:

- The patient was a 17 year old male brought to the hospital by police for cutting himself.
- The patient's medical history and diagnoses were Bipolar Disorder, Oppositional Defiant Disorder and previous suicide attempt in 12/2016 by drinking bleach, current emotional and verbal abuse, difficulty sleeping, eats one meal per day, current stressor of ex-girlfriend, stepmother and brother.
- The patient's stepmother and brother told him to kill himself.
- The patient's mother completed suicide in 07/2016.
- The patient denied any current medications and stated that he didn't have the money for them.
- The patient was under arrest due to resisting arrest when police attempted to escort him to the hospital for a mental health evaluation.
- The patient's mood was angry and agitated.

Record review of the patient's observation flow sheet showed that the patient was on suicide precautions between 3:34 PM and 5:30 PM. The documentation also showed that the patient was angry at first, and then cried for 45 minutes.

During an interview on 07/26/17 at 10:55 AM, Staff C, Registered Nurse (RN), stated that Patient #25 stated, "My family wants me to kill myself." She also stated that the patient needed mental health treatment and that he did not have a flat affect.

During an interview on 07/27/17 at 9:20 AM, Staff K, ED Physician, stated that he didn't recall this patient, but for the most part they follow the recommendation of the mental health assessor. He also stated that if a patient is suicidal and in police custody they will go back to jail on a 24 hour suicide watch.

During an interview on 07/27/17 at 10:15 AM and 1:50 PM, Staff L, Mental Health Assessor, stated that:
- When the police have a hold on the patient, they are unable to place them in an inpatient facility.
- She didn't know why the police brought the patients to the ED, if they wouldn't let them go to an inpatient facility.
- She should have documented her recommendation for inpatient treatment.

The facility failed to provide stabilizing treatment within its capabilities and capacity prior to discharging Patient #25, placing the patient at risk for further injury or death.