HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure all patients who presented to Hospital A's emergency department (ED) had an appropriate medical screening exam. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete psychiatric evaluation for 1 (#2) of 12 (#1, 2, 4, 6, 7, 11, 13, 15, 16, 17, 18, 19) patients who presented to the emergency department with suicidal ideation.

Findings:

A review of Patient #2's medical record revealed he presented to Hospital A's ED on 2/23/2023 at 7:37 a.m. Patient was triaged at 7:43 a.m., level 4 Non-Urgent, for a minor complaint with a history of depression.
Suicide Risk Assessment done at 7:48 a.m. which patient denied suicide thoughts.
Patient seen by S7MD at 7:38 a.m. and no orders noted. It is documented that the patient stated that he wanted help with alcohol and marijuana usage, and he had also been fighting with his girlfriend and nephew. After S7MD evaluation, S7MD documented that she explained to patient that housing was not a reason for hospitalization, and then patient responded "well then I think I will have to suicide myself". S7MD discharged patient home to follow up with mental health appointment on 2/23/23 at 1:00p.m. Patient refused to sign discharge instructions or take instructions with him when leaving the ED. Patient #2 was discharged at 8:11 a.m. on 2/23/23.

On 03/14/2023 an observation of Hospital A's lobby video footage dated 2/23/2023 revealed Patient #2 standing in the doorway of Hospital A's ED and S8Vol walked over to him. Patient #2 then removed a plastic umbrella bag from the holder. S4Sec walks over to Patient #2. S4Sec walked back to desk and Patient #2 walked towards him. Patient #2 then walks out of view outside with the plastic bag in hand.

On 03/14/2023 an observation of Hospital A's outside camera dated 2/23/2023 revealed at 8:17:10 a.m. per the camera timer Patient #2 places the plastic bag over face and places his hands near the back of his head walks away from Hospital A's ED and removes the bag and then places it back over his face. Patient #2 slowly walks to the sidewalk near the busy street with numerous vehicles passing. Patient #2 remains on the sidewalk and police arrive at 8:25:36 a.m. per the timer on the camera. At 8:29 a.m. per the video camera a second police officer arrives. Patient #2 remains on the sidewalk in front of Hospital A. A third police officer arrives at 8:30 a.m. per the camera time.

In an interview on 03/13/2023 at 10:42 a.m. S1OpMgr stated Patient #2 was in the lobby and grabbed a plastic umbrella bags and exited Hospital A's ED after being asked to leave by S4Sec. S1OpMgr further stated Patient #2 was witnessed by S4Sec walking down the sidewalk in the hospital parking lot placing the plastic bag over his head. S1OpMgr also stated Patient #2 walked off Hospital's A property and the police arrived after being called by hospital security. S1OpMgr stated the police called Ambulance A and one of the ambulance employees walked back to Hospital A's ED and spoke with S7MD.

In an interview on 03/13/2023 at 11:45 a.m. S4Sec stated he was working the day Patient #2 was in Hospital A's ED. He also stated Patient #2 was discharged, did not want to leave the lobby and stated he was suicidal and placed a clear plastic bag over his head. S4Sec stated Patient #2 removed the bag and S4Sec stated he instructed Patient #2 to leave or he would have to call the sheriff's office. S4Sec said Patient #2 walked towards the highway and the sheriff and ambulance showed up.

In an interview on 03/13/2023 at 1:20 p.m. S7MD stated we were not quite sure why he was here. She said she tried to look him up in the computer prior to seeing the patient and noted he was recently hospitalized and she read his record. Pt was not sure of the medications he was on or was supposed to be taking. Patient #2 could not answer what his concerns were with his medications. He had an appointment in a few hours with outpatient mental health clinic. Patient was not happy about being discharged and said something along the line of, Well I'm going to suicide myself. S7MD stated that S5RN said she tried to give Patient #2 his discharge paperwork and he refused to take any of it. S7MD said she was told Patient #2 was in the parking lot putting a plastic bag over his head. S7MD said an employee of Ambulance A came back to Hospital A's ED to get information about Patient #2. S7MD said he could come back in Hospital A's ED if he wanted to.

In an interview on 03/13/2023 at 1:00 p.m. S5RN stated she triage Patient #2. S5RN said Patient #2's exact words were I'm going to suicide myself in the parking lot. S5RN said Patient #2 refused his discharge paperwork and S7MD was present when Patient #2 stated he was going to suicide himself in the parking lot. S5RN stated she spoke with S10EMT. S5RN stated she told S10EMT that the patient was not suicidal and then started saying he was suicidal when he did not get what he wanted. S5RN stated she could see Patient #2 on the video camera in Hospital A's ED placing and removing the plastic bag over his head.

In an interview on 03/13/2023 at 1:50 p.m. S8Vol states she was working in Hospital A's ED on the day Patient #2 came to Hospital A's ED. Patent #2 came out of Hospital A's ED into the lobby pacing around. S8Vol said Patient #2 said he was going to suicide himself when asked if she could help him. S8Vol called Hospital A's ED nurses station and told them that she had a patient in the lobby who said he wanted to suicide himself. S4Sec from security came out and tried to talk to Patient #2 and he said he was going to suicide himself. He was walking in and out of Hospital A's ED. S8Vol stated she next saw him at the highway with the sheriff.

In an interview on 03/13/2023 at 2:05 p.m. S9RN stated she initially did Patient #2's vital signs for triage. S7MD looked Patient #2 up in the computer and noted he had a mental health appointment at 1:00 p.m. S9RN states she heard Patient #2 say he was going to suicide himself.

In an interview on 03/13/2023 at 2:40 p.m. S4Sec stated S9RN told him Patient #2 was discharged and they needed the patient to leave. When walking outside Patient #2 said he was going to commit suicide. Patient #2 placed a clear plastic bag over his head. S4Sec said Patient #2 was right at the door of Hospital A's ED. S4Sec stated he called the Sheriff. Patient #2 was at the edge of the hospital property. S4Sec was not sure if Patient #2 was on the sidewalk or parking lot.

In an interview on 03/14/2023 at 12:35 p.m. S3Reg stated they were not aware as to who the police officers were. She also denied any staff approaching the patient or police. She also denied having any video footage of the ambulance arrival.

In an interview on 03/14/2023 at 12:38 p.m. S1OpMgr stated he was under the pavilion outside Hospital A's ED and one of the ambulance personnel came to Hospital A's ED and spoke with S7MD. He also denied any staff going to check on the patient.

In an interview on 03/15/2015 at 4:00 p.m. S10EMT stated she works for Ambulance A and had received a call for a suicidal patient. S10EMT stated as she was driving up Patient #2 was near the side walk but on Hospital A's property. She then stated she pulled the ambulance into the hospital parking lot and Patient #2 with the sheriff walked over to ambulance. S10EMT said the Sheriff had the plastic bag Patient #2 was placing over his head. Patient #2 admitted being suicidal and was placing the plastic bag over his head. S10EMT then walked to Hospital A's ED and spoke with S4Sec, who told her the patient was discharged and the patient got the plastic bag from the hospital's lobby after saying he was going to suffocate himself. S10EMT then spoke with S4MD, who said the Patient #2 originally came in for substance abuse and withdrawal, home life issues with his nephew and girlfriend being pregnant, and the Patient wanted to be PECd, Physicians Emergency Certification. S4MD said Patient #2 made suicidal comments before leaving the hospital. S10EMT repeated that Patient #2 made suicidal statements and S4MD said yes. S10EMT stated Hospital A's ED staff never once said to bring him back in to Hospital A's ED. She also denies any staff going outside to check on Patient #2. S10EMT denies S4MD stating S10EMT could bring Patient #2 back into Hospital A's ED.

A review of Patient #2's medical record from Hospital B revealed he was admitted to Hospital B's ED on 02/23/2023 at 9:04 a.m. Patient #2 arrived via Ambulance A, who reported Patient #2 was picked up with the police on scene removing a plastic bag from Patient #2's head.
A review of the physician mental health problem states: Presenting Problem: suicidal thoughts. Further review revealed Psychiatric: Thought Content: Thought content includes suicidal ideation. Thought content includes suicidal plan.
Patient #2 was placed on suicide precautions.
Patient #2 was PECd on 02/23/2023 at 9:45 a.m. and transferred to inpatient psychiatric Hospital C.

A review of Patient #2's medical records from Hospital C revealed he was admitted on 02/23/2023 at 6:00 p.m. with a chief complaint of suicidal ideation. Patient #2 remained hospitalized until his discharge on 03/08/2023 at 10:50 a.m.







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