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Based on interview and review of Emergency Department (ED) logs, the facility failed to provide one patient (#14) of 29 with a Medical Screening Examination (MSE) sufficient to determine the presence of a medical and or psychiatric emergency within its capacity and capability of 29 patients' ED records reviewed.

Please see A2406 for details.

Based on interview, record review, and policy review, the hospital failed to provide a medical screening examination sufficient to determine the presence of a medical and/or psychiatric emergency, within its capacity and capability, for one patient (#14) of 29 patients' Emergency Department (ED) records reviewed. This had the potential to cause injury or death to all patients who presented to the ED with a medical and/or psychiatric emergency. The ED sees approximately 1375 patients per month. The facility census was 112.

Findings included:

1. Record review of the facility's policy titled, "Admission/Registration to the Emergency Department," revised 01/2017, showed the following:
- Patients presenting for treatment of any injury and/or illness will receive a Triage Assessment (process of determining the priority of a patients' treatment based on the severity of their condition) by a registered nurse to determine the order in which patients are seen by a Physician/Nurse Practitioner or Physician Assistant.

- Physician or Nurse Practitioner or a Physician's Assistant will perform an appropriate Medical Screening Examination (MSE, a strategy to identify undiagnosed disease in an individual) provided within the capabilities, including ancillary services, to determine if an Emergency Medical Condition (EMC, medical condition manifesting itself that absence of immediate medical attention could result in serious jeopardy to the patient's health) exists.

- An EMC is a medical condition that manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

- Each time a patient presents to the ED, they are registered as a new patient, triaged, have a MSE, and are provided with appropriate treatment.

Review of the facility's policy titled, "Patient Assessment/Reassessment," revised 02/2011, showed the following:
- All patients at the facility receiving inpatient, outpatient, or emergency services will have a timely, initial assessment of pertinent medical and psychosocial variables by qualified, privileged, interdisciplinary health care providers.

- The assessment process will direct the creation of the patient's plan of care including determining the need for care and/or treatment and the type of care and services to be provided.

- The reassessment is the evaluation of patient's response to treatment and care in order to determine the appropriateness and effectiveness of the patient's plan of care.

2. Review of the ED triage assessment performed by ED nurse Z, dated 10/17/16, at 2:18 AM, showed that Patient #14:
- Presented to the ED by ambulance;
- Had suicidal ideation (SI, thoughts to harm self or kill himself) for four days, with a plan to "jump in front of a Metro Bus".
- Was screened as a suicide risk.

Review of the medical record showed ED physician X, examined patient # 14 on 10/17/16, at 2:37 AM, and documented the following:
- Patient # 14 complained of worsening depression for four days;
- Had suicidal ideations with a specific plan, "to jump out of a bus";
- Had acute exacerbation of Schizophrenia (a disorder that affects a person's ability to think or behave clearly);
- Complained of being depressed, angry, frustrated, agitated, hostile, and paranoid; and
- Had auditory hallucinations (false perceptions of internal words or noises).

Review of the Psychiatric Intake Assessment performed by Psychiatric Intake nurse W, dated 10/17/16, at 2:35 AM, showed that the patient voiced suicidal ideation's (SI) with a plan, and that the patient was homeless.

During a telephone interview on 02/01/17, at 12:25 PM, Psychiatric Intake nurse W, stated that she did not recall the patient, but she did not believe in discharging a patient with SI. She stated that she would call her supervisor and document in the progress notes that she was uncomfortable with the discharge.

During an interview on 02/02/17, at 9:15 AM, Psychiatric Intake Clinical Leader GG stated that:
- She was the supervisor for Psychiatric intake nurse W.
- After review of Patient #14's medical record, she was "shocked" that Patient #14 was discharged;
- "There is no reason for discharging Patient #14 with SI, we could have held or transferred the patient."

Review of the disposition record, performed by ED physician X dated 10/17/16, at 2:48 AM, showed that Patient #14's condition was "unchanged".

Record review of the MSE, performed and signed by ED physician X dated 10/17/16, at 3:00 AM, showed no further evaluation or reassessment of Patient #14's SI.

Record review of telephone orders received from Psychiatrist Y, dated 10/17/16, at 3:11 AM, showed to "discharge the patient home, and follow up in her office today."

Record review of ED Discharge Assessment performed by ED nurse Z dated 10/17/16, at 4:12 AM, showed the patient was discharged from the ED at 4:12 AM to home.

Review of Patient #14's medical record dated 10/17/16, at 2:37 AM through 4:12 AM, showed no evidence
ED physician X and Psychiatrist Intake nurse W performed a reassessment of Patient #14's SI.

Review of the 10/17/16 inpatient census for the hospital's third and fourth floor psychiatric unit showed there were two open patient beds, one on each floor.

During a telephone interview on 02/01/17, at 12:50 PM, ED physician X stated that:
- Once the patient was medically cleared and psychiatric intake was notified, the patient became the responsibility of the Psychiatrist.
- His understanding was Patient #14 was admitted to inpatient care because a patient with SI and a plan should not be discharged.
- ED nurse Z and Psychiatric Intake nusre W did not communicate with him about Patient #14 being discharged by the Psychiatrist.
- A reassessment of Patient #14's SI should have been completed prior to discharge.

During a telephone interview on 02/01/17 at 12:55 PM, Psychiatrist Y, stated that:
- She could not recall the conversation with Psychiatric Intake nurse W regarding Patient #14;
- The on call Psychiatrists were just a consult to the ED physicians;
- The ED physicians are responsible for the patients;
- Patients with SI and a plan should not be discharged; and
- Reassessment of the patient's mental status should be documented prior to discharge.

During a telephone interview on 02/01/17, at 4:00 PM, ED Medical Director CC stated that a reassessment of Patient #14's SI should have been performed by the ED physician or nurse prior to being discharged home.

The medical record did not contain evidence that patient # 14 received an appropriate and sufficient medical screening examination within the hospital's capabilities to determine whether or not a psychiatric emergency medical condition existed prior to discharge. The evidence in the medical record showed that patient # 14's condition remained "unchanged" at the time of discharge. On 10/17/16 at 4:12 am, the time of discharge, ED staff instructed the patient to contact Psychiatrist Y's office to arrange an appointment for later in the morning which would have delayed by five or more hours, further examination and treatment of patient # 14's potential psychiatric emergency medical condition.








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