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Based on record review and policy review, the hospital failed to follow its policies and procedures when it did not provide an appropriate medical screening exam (MSE), within its capability and capacity, for one patient (#20), of 32 Emergency Department (ED) records reviewed from 03/12/22 through 09/12/22. Patient #20 presented to the ED on 06/30/22 clinically intoxicated, slurring his speech and was verbally aggressive with staff. No mental health evaluation (MHE) was provided or bloodwork tested, and the patient was discharged to the custody of law enforcement. On 07/17/22, Patient #20 presented to the ED for an MSE while in police custody. He attempted to pull away from the officers, threatened physical violence and lunged toward hospital staff. No MHE was performed and the patient was discharged to the custody of law enforcement. On 07/28/22, the patient presented to the ED for dehydration. He became agitated, aggressive, and threatened physical harm to the ED staff, stating he would stab them. A MHE was not ordered or completed before the hospital staff allowed the patient to be escorted off the premises by law enforcement. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 2,210.

Findings included:

Review of the hospital's policy titled, "Emergency, Treatment, and Transfer for Emergency Medical Conditions and Women in Labor (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," dated 10/05/21, showed that:
- Patients shall not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint, condition or lack of physician on the medical staff of this hospital.
- Patients presenting with symptoms of psychiatric (relating to mental illness) disturbances were considered to have an EMC under federal law and shall receive a medical screening and a MHE.
- Under federal law, symptoms of substance abuse, including alcohol, was considered an EMC.
- Patients presenting with complaints associated with alcohol substance abuse as their primary complaint or secondary complaint or observed condition shall receive a MSE appropriate to the complaint and sufficient to rule out the presence of an EMC, including psychiatric that may cause symptoms or effects that may be mistaken for intoxication and EMC that may be masked by alcohol intoxication.
- Patients refusing examination, treatment or transfer shall be provided with information regarding the risks versus benefits of refusal and this shall be documented on a "Refusal of Services" form.

Review of a law enforcement report dated 06/30/22 at 8:21 PM, showed that Patient #20, was found passed out on a sidewalk, snoring and was not initially responsive to verbal contact. The officer had to tap the patient on the foot for 10 seconds before the patient awoke. The patient threatened the officers stating he would murder them. The patient smelled strongly of alcohol, had dilated pupils and was unsteady on his feet. He was unable to balance himself, began swaying, and nearly fell over attempting to punch an officer. He was transported to the hospital for a fit for confinement (to determine if a person is medically and psychiatrically stable to go to jail). Once at the hospital the patient threatened nurses and officers.

Review of Patient #20's ED record dated 06/30/22 at 8:41 PM, showed that he presented with law enforcement for a MSE and a fit for confinement. The physician documented that the patient had a history of alcohol use and was found unconscious on the sidewalk. It was documented that the patient was clinically intoxicated, slurring his speech, was verbally aggressive and endorsed the use of alcohol. No MHE was performed, no laboratory studies were obtained, and the patient was discharged to the custody of law enforcement. His length of stay in the ED was 27 minutes.

Review of a law enforcement report dated 07/17/22, showed that Patient #20 was picked up for trespassing at a gas station. Due to his belligerent state, he was taken to the hospital to confirm he was fit for confinement. During transport to the hospital, Patient #20 threatened multiple times to kill or shoot the officer. While in the ED, the patient attempted to pull away from the officers, threatened physical violence toward hospital staff multiple times, lunged at staff, and had to be restrained by law enforcement. The hospital determined the patient was fit for confinement and he was discharged back into law enforcement custody.

Review of Patient #20's ED record showed that he presented with law enforcement on 07/17/22 at 1:31 AM, for a fit for confinement. Admission documentation showed that the patient entered the ED handcuffed and was cursing and spitting at the officers and staff. The patient was fighting with two officers and refused to comply in completing admission paperwork. The physician documented that a review of systems (questions asked to identify signs and/or symptoms that the patient may be experiencing) was not completed because of the patient's hostile behavior. The patient was screaming and yelling and made several attempts to assault officers. The patient threatened violence against the medical team, stating that he would "murder everybody." No MHE was performed, no vital signs or laboratory studies were obtained, and the patient was discharged to the custody of law enforcement. His length of stay in the ED was 14 minutes. There was no Refusal of Services documented, and no documentation that the patient was provided with information regarding the risks versus benefits of refusing examination or treatment.

During a telephone interview on 09/14/22 at 3:38 PM, Staff N, ED Physician, stated that when Patient #20 presented on 07/17/22, he was "calm" with Staff N, of "sound mind," and refused treatment. Staff N stated that the patient did not present with psychiatric complaints, did not have a psychiatric emergency, and therefore never received a MHE. The patient denied medical issues and did not smell of alcohol, and because the patient refused treatment, no alcohol or drug screen was obtained. Staff N added that CRMC did not have psychiatric services; however, if a patient presented as an immediate danger to self or others as the result of an underlying psychiatric disease, it would be appropriate to restrain the patient and administer medication to sedate the patient, in order to obtain a complete MSE or MHE.

Review of Patient #20's ED record showed that he presented on 07/28/22 at 1:11 AM, with a stated complaint of dehydration. The patient became agitated, aggressive, and threatened physical harm to the ED staff, stating he would stab them. The physician documented that a review of systems could not be completed because the patient would not cooperate, and that staff would not be endangered for what was believed to be "malingering behavior" (to fake psychological or physical symptoms for secondary gains). No MHE was performed, and no vital signs or laboratory studies were obtained. The physician determined that the patient had no "apparent" EMC, and the patient was "escorted out of the ED" by law enforcement at 1:47 AM, with a discharge disposition of left without being seen (LWBS). There was no Refusal of Services form completed, and no documentation that the patient was provided with information regarding the risks versus benefits of refusing examination or treatment. His length of stay in the ED was 36 minutes.

During a telephone interview on 09/13/22 at 2:30 PM, Staff K, ED Medical Director, stated that he considered statements threatening to stab others as homicidal ideations (HI, thoughts or attempts to cause another's death) and that HI was an indication that the patient needed a MHE. Staff K stated that he expected a full MSE and MHE to be completed on a patient who was aggressive and homicidal.

During an interview on 09/12/22 at 4:05 PM, Staff E, Quality Director, stated that the hospital's Mental Wellness Center staff were used to conduct MHE's, and available Monday through Friday from 8:00 AM to 8:00 PM, and on Saturday and Sunday from 8:00 AM to 11:00 PM. If a patient came to the ED outside of those times, the patient waited until morning for a MHE.

During an interview on 09/13/22 at 2:55 PM, Staff C, ED Director, stated that the ED had the ability to hold a patient until morning for a psychiatric evaluation, if they presented after Mental Wellness Center hours, or a patient could be transferred to a psychiatric facility for a psychiatric evaluation .

Review of a law enforcement report, affidavit, application and court-ordered hold dated 07/28/22, showed that law enforcement were called to the hospital at approximately 1:40 AM for a person making threats. Upon officers arrival, Patient #20 was aggressively yelling at a nurse, and was placed in handcuffs to de-escalate the situation. The nurse reported that the patient had been verbally aggressive and had stated that he was going to stab everyone and kill them. The patient was arrested for "terrorist threats and assault" and continued to threaten the law enforcement officers as they left the ED. The patient was then transported to the local county jail where law enforcement obtained a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) and transported the patient to Hospital B (hospital with inpatient psychiatric services) at 4:32 AM.

Review of Patient #20's ED record from Hospital B, dated 07/28/22, showed that the patient presented to the ED with law enforcement at 4:08 AM, with a 96-hour court ordered hold and a chief complaint of violent behavior and HI. The patient was admitted for further psychiatric evaluation and medical care related to COVID-19, after he tested positive for the virus.

Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) for three of Patient #20's presentments between 06/30/22 and 07/28/22, out of 32 Emergency Department (ED) records reviewed from 03/12/22 through 09/12/22. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 2,210.

Findings included:

1. Review of the hospital's policy titled, "Emergency, Treatment, and Transfer for Emergency Medical Conditions and Women in Labor (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," dated 10/05/21, showed that:
- Patients shall not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint, condition or lack of physician on the medical staff of this hospital.
- Patients presenting with symptoms of psychiatric (relating to mental illness) disturbances were considered to have an EMC, and shall receive a medical screening and a mental health evaluation (MHE).
- Under federal law, symptoms of substance abuse, including alcohol, was considered an EMC.
- Patients presenting with complaints associated with alcohol substance abuse as their primary complaint or secondary complaint, or observed condition, shall receive a MSE appropriate to the complaint and sufficient to rule out the presence of an EMC, including psychiatric that may cause symptoms or effects that may be mistaken for intoxication, and EMC that may be masked by alcohol intoxication.
- Patients refusing examination, treatment or transfer shall be provided with information regarding the risks versus benefits of refusal and this shall be documented on a "Refusal of Services" form.

Review of local law enforcement's document titled, "Investigative Narrative," dated 06/30/22 at 8:21 PM, showed that Patient #20 was passed out on a sidewalk, snoring, and was not initially responsive to verbal contact. The officer tapped the patient on the foot for 10 seconds before the patient awoke. The patient threatened the officers and stated he would murder them. The patient smelled strongly of alcohol, had dilated pupils and was unsteady on his feet. He was unable to balance himself, began swaying, and nearly fell over as he attempted to punch an officer. He was transported to the hospital for a fit for confinement (to determine if a person is medically and psychiatrically stable to go to jail). Once at the hospital, the patient threatened nurses and officers.

Review of Patient #20's ED record dated 06/30/22 at 8:41 PM, showed that the patient was a 43 year old male who presented with law enforcement for a MSE and a fit for confinement. He was an alcohol user, and had a documented history of ongoing alcohol intoxication. Nursing staff documented that the patient was intoxicated upon arrival, was with law enforcement, was screaming, threatening and angry. The physician documented that the patient endorsed the use of alcohol, was clinically intoxicated, and had been found unconscious on the sidewalk. The patient was slurring his speech, and was verbally aggressive. No MHE was performed, no laboratory studies were obtained, and the patient was discharged to the custody of law enforcement. His length of stay in the ED was 27 minutes.

During a telephone interview on 09/29/22 at 4:35 PM, Staff R, ED Physician, stated that when Patient #20 presented to the ED, his speech was slurred and he was yelling at staff, but was "neurologically fine." Staff R added that intoxication can mask an underlying EMC, and that patients could be kept in the ED and reevaluated when they were more sober.

Review of local law enforcement's document titled, "Investigative Narrative," dated 07/17/22, showed that Patient #20 was found arguing with several males on a local business lot, belligerent, and was picked up for trespassing. He was transported by law enforcement to Capital Region Medical Center (CRMC), to determine if he was fit for confinement. During transport, Patient #20 threatened multiple times to kill or shoot the officer. While at the hospital, the patient continued to threaten to shoot or stab officers, stating he would kill the officers. The patient attempted to pull away from the officers, threatened hospital staff with violence, lunged toward them, and had to be restrained by the officers. The hospital determined the patient was fit for confinement and he was discharged back into the custody of law enforcement. During transport to the local jail, Patient #20 continued to threaten the transporting law enforcement officer, stating that he would kill him the next time he saw him.

Review of Patient #20's ED record dated 07/17/22, showed that he presented to the ED on 07/17/22 at 1:31 AM, for a fit for confinement examination. During registration of the patient, a hand written note on the consent to treat form, indicated that the patient arrived in handcuffs, cursing, spitting at officers and staff, and fighting with two officers. Nursing documented that upon arrival, the patient was screaming, using racial slurs, spitting and refused to cooperate. He had a history of alcohol abuse and intoxication. Staff N, ED Physician, documented that there was no review of systems (ROS, questions asked to identify signs and/or symptoms that the patient may be experiencing) conducted due to the patient's hostile behavior. The physician's examination of the patient's head, eyes, ears, nose and throat was conducted through a spit hood that had been placed on the patient by law enforcement officers. The physician documented that the patient was hostile screaming, yelling, stated, "Fuck you bitch, I have no problems," and tried to assault officers multiple times in the examination room. The patient was hostile towards any medical exam, threatened violence against the physician, nurses and law enforcement, and threatened to "murder everybody." He was determined fit for confinement and was discharged to the custody of law enforcement. Patient instructions noted, "He is hostile and agitated which does limit the evaluation slightly." There were no vital signs documented. The patient's length of stay was 14 minutes when he was discharged to law enforcement custody at 1:45 AM. The Coding Summary/Visit Reasons showed that the encounter was for blood-alcohol level (BAL, the amount of alcohol in the blood) and blood-drug test. There were no laboratory blood draws documented. There was no MHE requested or documented. There was no Refusal of Services documented, and no documentation that the patient was provided with information regarding the risks versus benefits of refusing examination or treatment.

During a telephone interview on 09/14/22 at 3:38 PM, Staff N, ED Physician, stated that when Patient #20 presented on 07/17/22, he was "calm" with Staff N, of "sound mind," and refused treatment. Staff N stated that the patient did not present with psychiatric complaints, did not have a psychiatric emergency, and therefore never received a MHE. The patient denied medical issues and did not smell of alcohol, and because the patient refused treatment, no alcohol or drug screen was obtained. Staff N added that CRMC did not have psychiatric services; however, if a patient presented as an immediate danger to self or others as the result of an underlying psychiatric disease, it would be appropriate to restrain the patient and administer medication to sedate the patient, in order to obtain a complete MSE or MHE.

Review of Patient #20's ED record dated 07/28/22, showed Patient presented to the ED on 07/28/22 at 1:11 AM, with a stated complaint of dehydration. Nursing documented that security reported the patient was yelling and threatening visitors in the waiting room and was placed in an examination room. The patient stated, "I will killl all of you all" and yelled obscenities. Triage (process of determining a priority of a patient's treatment based on the severity of their condition) was not completed due to the patient's aggressive behavior, and law enforcement was contacted. Staff M, ED Physician, documented that the patient presented "extremely" agitated and aggressive. He was unable to be de-escalated and had threatened the triage nurse that he would "stab us all." The patient requested an intravenous (IV, for hydration), but was "distracted by perceived bigotry" on the part of the staff and physician. When the physician challenged the patient's comment, the patient became increasingly violent in speech with posturing (positioning of body in an aggressive manner). The physician documented that she was "unable" to gather the rest of the patient's history due to his aggressive behavior and "lack of focus on his reason for visit," and deferred a physical (hands-on) examination due to "patient attitude." The physician documented that staff safety was her major concern, and that she would not endanger her staff for what she believed was malingering (to fake psychological or physical symptoms for secondary gains) behavior. The patient appeared he was of "sound enough" mind, in control of his actions, and without "apparent" EMC. At 1:47 AM, the patient was escorted out of the ED in the custody of law enforcement, "in order to continue safety," with a discharge disposition of left without being seen (LWBS). There was no Refusal of Services form completed, and no documentation that the patient was provided with information regarding the risks versus benefits of refusing examination or treatment. His length of stay in the ED was 36 minutes. No vital signs were obtained, and there was no MHE requested or documented.

During a telephone interview on 09/13/22 at 3:08 PM, Staff L, ED RN, stated that Patient #20 had threatened visitors and staff, was upset and paced around the room while yelling. Staff L informed the charge nurse and Staff M, ED Physician, of the patient's behavior. Staff M was unable to get near the patient or evaluate him, so law enforcement was called. In certain situations, law enforcement would have stayed with the patient until an exam was completed, but the patient was fighting the officers, and was removed from the hospital.

During a telephone interview on 09/13/22 at 3:15 PM, Staff M, ED Physician, stated that Patient #20 was not safe to further evaluate at that time. The officers would only have restrained a patient if they were not of sound mind and had a psychotic episode. The only medical concern voiced was dehydration, therefore no MHE was performed. A MHE would have been performed if the primary chief complaint was homicidal ideations (HI, thoughts or attempts to cause another's death). A mental health screening was completed if the patient had a specific target related to his HI. Threats of HI by Patient #20 were conditional based on if staff attempted to touch him. The ED physician evaluated if the patient was safe for discharge or needed to wait for a psychiatric evaluation. The Center for Mental Wellness was only open during normal business hours.

During a telephone interview on 09/13/22 at 2:30 PM, Staff K, ED Medical Director, stated that he considered statements threatening to stab others as HI, and that HI was an indication that the patient needed a MHE. Staff K stated that he expected a full MSE and MHE to be completed on a patient who was aggressive and homicidal, and that the hospital's Mental Wellness Center performed MHE's during the day and evening hours.

During an interview on 09/13/22 at 2:55 PM, Staff C, ED Director, stated that the ED had the ability to hold a patient until morning for a psychiatric evaluation, if they presented after Mental Wellness Center hours, or a patient could be transferred to a psychiatric facility for a psychiatric evaluation.

Review of local law enforcement's document titled, "Investigative Narrative," dated 07/28/22, showed that Law Enforcement Officer Q and Law Enforcement Officer O, were called to CRMC by staff at approximately 1:40 AM for a person making threats. Once they arrived, Patient #20 was found sitting on the end of the bed, leaning forward in an aggressive manner yelling at Staff L, RN. The patient was then placed in handcuffs to de-escalate the situation. Staff L reported that the patient was verbally aggressive and that the patient stated to staff, patients and visitors that he was going to stab everyone and kill them. Staff M, ED Physician, reported that the patient was leaning forward and was verbally aggressive. Staff M reported that she attempted to treat the patient, but he continued to threaten everyone in the ED. Due to his aggressive behavior, and the uncertainty if the patient would carry out the threats, 911 was called. The patient was removed from the ED and arrested for "terrorist threats and assault." The patient continued to threaten the officers as they left the ED. The patient was then transported to the local jail where an affidavit was obtained for a 96-hour hold (court ordered evaluation by behavioral specialists to determine if a person was safe to themselves and others). The patient was then taken to Hospital B (nearby hospital with inpatient psychiatric services) for treatment.

During a telephone interview on 09/14/22 at 6:05 PM, Law Enforcement Officer O, stated that when law enforcement were called to the hospital on 07/28/22, the patient was yelling at staff, threatened to kill people, shoot them and blow up the place. The patient had very unpredictable behavior, with a history of violence and turned on people quickly. Patient #20 was very capable of hurting someone. The patient was handcuffed and taken out of the building.

During a telephone interview on 09/14/22 at 5:55 PM, Law Enforcement Officer Q, stated that the patient was well known to local law enforcement, and "had a lot of mental health issues." Patient #20 commonly made threats to everyone, law enforcement included. When law enforcement arrived to the hospital ED on 07/28/22, the patient continued to yell at staff, became uncooperative and threatened to kill everyone. The patient was a "huge threat to everyone around at that point." Staff M, ED Physician, attempted to de-escalate the patient, but the patient was not in his right mind. The patient was handcuffed, removed from the hospital, a 96-hour hold was obtained, and the patient was taken to Hospital B.

Review of Patient #20's ED record from Hospital B, dated 07/28/22, showed that the patient presented to the ED with law enforcement at 4:08 AM, with a 96-hour court ordered hold and a chief complaint of violent behavior and HI. The patient was admitted for further psychiatric evaluation and medical care related to COVID-19, after he tested positive for the virus.

Review of Hospital B's documented titled, "Psychiatry Note," dated 07/28/22, showed that when Patient #20 presented, he was agitated and in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). Psychiatric examination showed that the patient endorsed HI, was agitated, restless and with poor eye contact. The patient's speech was increased in volume and rate, with an angry tone. The patient's insight and judgement was limited, and was an imminent risk of harm to others. Though the patient denied alcohol or drug use, he appeared to have been acutely under the influence of substances and a drug screen was requested. At that time, it was unable to be determined if the patient's symptoms were caused by alcohol/drugs or from a primary mental health diagnosis. The patient's pattern of behavior and the behavior that was exhibited, was likely a consequence of an underlying personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving).

During a telephone interview on 10/03/22 at 12:20 PM, Staff S, Hospital B's Physician Assistant (PA), stated that the patient presented in four-point restraints, had HI, was agitated and she felt the patient was acutely intoxicated. The patient's drug screen came back positive for cannabinoids (chemical compounds of marijuana) and cocaine (an addictive drug used as an illegal stimulant), which was consistent with his level of agitation. The patient thought law enforcement were profiling him and that he had done nothing wrong. Patient #20 stated to Staff S, "Kill or be killed." She stated that because the patient had imminently threatened to hurt others, she continued the 96-hour hold.

During a telephone interview on 10/03/22 at 2:05 PM, Staff T, Hospital B's Psychiatrist, stated that if a patient had threatened to stab staff, it would have been considered as HI. He expected a psychiatric consult made if a patient exhibited behavioral symptoms. He stated that a person had the right to be scared, but the patient still needed an assessment. If a patient posed immediate harm to others, it would have been considered an EMC and would have required at least a MHE of the patient.

2. During an interview on 09/13/22 at 2:55 PM, Staff C, ED Director, stated that the ED had the ability to hold a patient until morning for a psychiatric evaluation, if they presented after Mental Wellness Center hours, or a patient could be transferred to a psychiatric facility for a psychiatric evaluation.

During an interview on 09/12/22 at 4:05 PM, Staff E, Quality Director, stated that the hospital's Mental Wellness Center staff were used to conduct MHE's, and available Monday through Friday from 8:00 AM to 8:00 PM, and on Saturday and Sunday from 8:00 AM to 11:00 PM. If a patient came to the ED outside of those times, the patient waited until morning for a MHE.

Review of two medical records showed that patients who presented to the ED with a psychiatric emergency remained in the ED until Mental Wellness Center staff were available to conduct an MHE. Patient #27's ED record showed that he presented on 06/16/22 at 11:23 PM with SI and drug addition, received a MHE the following day, and was subsequently transferred for inpatient admission and stabilization of his EMC. Patient #25's ED record showed that he presented on 08/22/22 at 1:10 AM with SI, received a MHE the following day, and was subsequently transferred for inpatient admission and stabilization of his EMC.