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Based on record review and interview the hospital failed to ensure compliance with 489.24 (a)(1)(i) Medical Screening Exam on 1 of 1 (Patient #1) who did not receive a complete medical screening exam on 03/25/24 for a patient presenting to the Emergency Department from a psychiatric facility.

Cross refer A2406

Based on record review and interview the facility failed to provide an appropriate Medical Screening Exam on 1 of 20 (Patient #1) patients when they presented to the emergency department on 03/25/24. The hospital failed to keep the patient safe until the complete medical screening exam could be achieved to determine if the patient had a medical or psychiatric emergency. The patient eloped from the hospital and was hit by a motor vehicle a killed on 03/25/24.

Findings included:

Patient #1 was transferred to the facility via ambulance from an inpatient psychiatric facility on 03/25/24 at 12:27 AM after falling twice. The Emergency Department (ED) record reflected..."Chief Complaint Fall...Upon arrival to ED patient jumped off stretcher and ran out ambulance bay. Paramedic able to speak to patient and bring her back inside and she agreed to stay. Pt (patient) reports, 'I don't want to go back to (inpatient psychiatric hospital)...Something doesn't feel right'... "

The ED Provider Notes by Personnel #6 dated 03/25/24 at 12:46 AM reflected..."presents via EMS (no APOWW, or police accompaniment) [emergency medical service/apprehension by peace officer without a warrant] from (inpatient psychiatric hospital). She was reportedly admitted on 03/17/24 for bipolar/depression per their nurse report...she also swallowed quarters a week ago...she referred to herself in the third person...Patient screened low risk for SI (suicidal ideation) and was not accompanied by police...Review of Systems...Musculoskeletal: Negative for back pain and neck pain...Neurological: negative for light-headiness and headaches. Psychiatric...decreased concentration and dysphoric mood...nervous/anxious...Physical Exam...Head: Normocephalic and atraumatic...Musculoskeletal: General : Normal range of motion. Cervical back: Normal range of motion and neck supple...Neurological: Mental Status: She is alert and oriented to person, place and time....No cranial nerve deficit...Psychiatric...Mood is anxious. Affect is Labile. Behavior normal...Thought content does not include homicidal or suicidal ideation...ED Course...01:29 AM Per nursing the patient may have eloped... 03:17 AM Still refusing all care...03:22 AM The patient eloped from the ED (had sitter). She refused MAT (mental health) assessment and said she did not have SI..."

The ED Notes dated 03/25/24 at 12:45 AM reflected..." Suicide Screening. Within the past month have you wished your were dead or wished you could go to sleep and not wake up? No..."

The patient was admitted to an inpatient psychiatric hospital on 03/17/24 for Bipolar Depression

The ED Notes dated 03/25/24 at 12:51 AM reflected..."I don't people. My mom
put me in Carrollton Springs because she is a narcissist and I don't trust the people at Carrollton Springs and I don't want to go back..."

The ED Notes Safety Assessment dated 03/25/24 at 01:20 AM reflected..."WDL (within defined limits)...Fall Risk...Low..."

The patient was transferred to the hospital from an inpatient psychiatric hospital for 2 falls prior to transfer. The patient eloped from the ambulance stretcher upon arrival at the hospital. There was not a documented elopement risk on the patient.

The ED Notes dated 03/25/24 at 01:29 AM reflected..."Behavioral health called for assessment-notified them pt no longer in the room...0215 Patient found by...PD (police department) at McDonald's and returned to ED...02:32 AM Pt asked 'what are my rights to leave AMA.' Pt was asked if she's willing/agreeable to get behavioral health assessment and pt agreed to do so...02:41 AM Pt now at nurses station stated she is going to leave...03:01 AM Patient does not want to wait for behavioral health assessment...Patient walking out of ED..."

The Behavioral Health Assessment was not completed; the patient was allowed to leave the hospital undeterred.

The ED Provider Notes dated 03/25/24 at 05:42 AM reflected..."arrives unresponsive. Reportedly she was struck by a car. Circumstances unknown at this time...The patient had significant trauma...she had no signs of life since trauma...ED Disposition...Deceased..."

During an interview with Personnel #5 on 03/28/24 at 11:30 AM Personnel #5 told the surveyor "when the patient arrived at the hospital they immediately jumped off the stretcher and ran outside. Personnel #5 said the patient stated she did not want to return to the psychiatric hospital. Personnel #5 said she told the patient they were sent to the hospital because of her falling earlier in the day. If the patient would agree to let the doctor see them, the hospital could get another behavioral health exam and if they agreed with the patient she could go home. Patient #1 came inside but eloped about five minutes before the behavioral health assessor called. Personnel #5 stated she called security and the police. The police found the patient across the street and brought her back to the ED. Personnel #5 said she asked the police officer that brought her back to write an APOWW, but they refused. Personnel #5 said the police officer told her that they had had an in-depth conversation with the patient and they were not suicidal and they had nothing to write an APOWW for. Personnel #5 said she asked the off duty police officer that works in the ED to write an APOWW and they also refused stating the patient was not suicidal. Personnel #5 said she called the psychiatric hospital to make sure the patient was a voluntary admission. The supervisor at the psychiatric hospital stated the patient was a voluntary admission. The patient had asked to leave the psychiatric hospital on 03/21/24 AMA. The supervisor stated they would have let the patient leave because she was no longer suicidal. Personnel #5 said the patient had been assigned a safety sitter because of her history of swallowing things. The safety sitter would not have prevented the patient from leaving the hospital without an APOWW. Personnel #5 said she had nothing to hold the on. Personnel #5 said the patient requested to sign out AMA and then walked back to their room with the sitter. The patient then eloped from the ED again. Personnel #5 said a couple of hours later the patient came back to the hospital after being hit by a car. The patient was deceased."

During an interview on 03/28/24 at 12:01 PM Personnel #6 told the surveyor "when the patient arrived at the hospital they immediately jumped off the stretcher and eloped out of the ambulance bay doors. Personnel #6 said he had the charge nurse call the psychiatric hospital to make sure the patient was a voluntary admission to that hospital. The charge nurse was told the patient was a voluntary admission for suicidal ideation. The patient had asked to leave AMA on 03/21/24 and would have been discharged AMA because they were no longer suicidal. The patient retracted the AMA and stayed at the facility. Personnel #6 told the survey two police officers refused to write an APOWW stating the patient was not suicidal. Personnel #6 stated he did not have a legal way to hold the patient without an APOWW."

Medical Screening Examinations and Patient Transfers policy. Last reviewed 10/07/2022.
5.10 Medical Screening Examination - Means the process to determine, with reasonable clinical confidence, whether the patient is suffering from an Emergency Medical Condition.