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Based on document review, policy review, record review and interview, the hospital failed to follow policy and ensure necessary stabilizing treatment was provided to two of 14 patients who presented to the emergency department (ED) with mental health or substance abuse concerns (Patients 5 and 12). Failure of the hospital to ensure stabilizing treatment is provided has the potential to place patients at risk for harm to themselves or others, including death.

Findings Include:

Review of a document title, "HUTCHINSON REGIONAL MEDICAL CENTER MEDICAL STAFF RULES AND REGULATIONS" signed by the CEO and Chief of Staff in 12/2018, showed ... B. Medical Screening Examination: All individuals seeking care shall be seen and provided an appropriate medical screening examination to determine whether or not an emergency medical condition exists. ...Treatment to stabilize the patient's emergency medical condition shall be provided within the facility's capabilities, and as determined appropriate. ...D. Transfer: Transfers to other institutions and discharges from the Emergency Services Department shall conform to the requirements of the Emergency Medical Treatment and Active Labor Act.

Review of a hospital policy titled, "Care of ED Patients with Psychiatric Complaints" revised 04/2020, showed, I. Purpose: To ensure safety and prevent injury for patients and hospital staff. To outline nursing management of the patient who is at risk for dangerous behaviors to self and/or others. II. Policy: A. Upon triage the Emergency Department (ED) any patient six (6) years and older will be evaluated for a psychiatric complaint that may lead to harm to self or others .... C. Physicians, APP (Advanced Practice Provider), and RN's (Registered Nurse) can place a medical hold for patients presenting in a crisis situation for patient safety. ...III. Scope: This policy applies to the safety of all psychiatric patients and ED Staff. IV. Guidelines: ...H. The crisis counselor will be consulted for evaluation of mental health problems as directed by the ED physician.

Review of a hospital policy titled, "Medical Screening Examination, Stabilization and Transportation Policy" last revised 12/2019 showed: ... Medical Screening Examination: The process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Screening is to be conducted to the extent necessary, by qualified medical personnel to determine whether an EMC exists. ... Stabilizing Treatment
Necessary medical interventions within the capabilities of hospital staff as required to stabilize the individual's condition and transportation of the individual to an appropriate medical facility.


Review of a hospital policy titled, "EMTALA Screening & Stabilization" most recently reviewed on October 27, 2020, showed: ...A. Definitions ...Emergency Medical Condition (EMC) means:

1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

a. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part. ...
3. With respect to psychiatric emergencies that:
a. Acute psychiatric or acute substance abuse symptoms are manifested; or
b. An individual is expressing suicidal or homicidal thoughts or gestures and we determine him/her to be a danger to self or others.

... H. EMC Clinically indicated:
1. EMC Obligations. If an EMC exists, HRMC must provide for (i) further medical examination and treatment to stabilize the medical condition within our capability and capacity; or (ii) an appropriate transfer to another medical facility if (A) HRMC is unable to stabilize an individual within our capacity; or (B) the individual requests the transfer. (See KK114 - T, EMTALA Transfer Policy).

2. Stabilize. To be stable, the treating physician or QMP must determine, within reasonable clinical confidence, that the EMC causing the person to seek care has been resolved, even if the underlying condition persists (e.g., asthma).
A. Generally. A person is stabilized if the treating physician or QMP determines that no material deterioration of the individual's condition is likely (within reasonable medical probability) to result from, or occur during, the transfer or upon discharge of the individual.

B. Pregnancy. We stabilize a woman in labor when we deliver the baby and placenta.

C. Psychiatric Conditions. We stabilize a psychiatric patient when we protect and prevent such patient from injuring or harming himself/herself or others.



Patient 5

Review of Patient 5's ED record showed she presented to the ED on 08/05/21 at 6:02 PM escorted by the police department (PD) and a community mental health service worker after being found trying to break into people's vehicles, she had gotten into someone's vehicle and then would not get out, so PD was called. Her diagnosis was methamphetamine (Meth) intoxication. She was discharged from the ED at 9:02 PM. Within 15-minutes of discharge from the ED, law enforcement was again called related to Patient 5's continued behaviors asking for rides and getting into a vehicle of someone she did not know, placing herself at risk for harm. There was no documented evidence in Patient 5's medical record to show her hallucinations had subsided and her behaviors stabilized before she was discharged out into the community. (Refer to A2407)


Patient 12

Review of Patient 12's ED record showed he presented to the ED on 08/12/21 at 5:46 PM, he was brought in by ambulance. He was witnessed driving in circles in a parking lot and making several statements he wanted to "die" and was hallucinating. The History of Present Illness showed, suicidal ideation (SI), hallucinations, chest pain and alcohol intoxication. Patient 12 complained of chest pain and pain all over. He reported he was having flashing hallucinations and describes them as delusions. Patient 12 stated that he felt suicidal for two weeks and stated, "I want to die." Discharge documentation showed: Discharged to care of: Law Enforcement; Discharge comments showed, Patient continues agitated; speaking over and refusing care. Paperwork handed to PD (police department). Patient 12 left the ED in police custody at 10:58 PM. There was no documentation of the absence of hallucinations or suicidal ideation to show Patient 12's emergency medical condition was stabilized before he was discharged from the ED. (Refer to Tag A2407)

Based on record review, interview, document review and policy review the Hospital failed to ensure necessary stabilizing treatment was provided to two of 14 patients who presented to the emergency department (ED) with mental health or substance abuse concerns (Patients 5 and 12). Failure of the hospital to provide stabilizing treatment for all patients who come to the Emergency Department (ED) seeking assistance, has the potential to place patients at risk for deterioration of the person's condition including harm or death.


Findings Include:


Patient 5

Review of a police report dated 08/05/21 at 5:35 PM, showed an officer responded to a call, in reference to a welfare check. Upon arrival he recognized Patient 5 in the front passenger seat of a pickup truck. Patient 5 had been crying on the street and the owner of the vehicle had pulled over to check on her. Patient 5 got into the passenger side of the vehicle and stated that the driver was her dad. The driver did not know who she was. Patient 5 would not exit the vehicle stating that her parents were outside the vehicle. [Patient 5] stated multiple times to me that [the driver] was her dad. I convinced [Patient 5] to sit in my vehicle while we talked. [Patient 5] did not have shoes on, was wearing a white T-shirt and shorts. Patient 5 wanted to get in contact with a named person, so he could give her the "right stuff to smoke." Patient 5 stated that this person was "changing into autobots all the time" and pointed at a random car going by stating that it was him. The report showed Patient 5 had a phone number written on her left arm. Upon calling the number, the driver of the truck picked up stating that he had given it to her in case she needed help. The report showed that it was clear Patient 5 did not know who the number belonged to and could not connect events. The note showed that Patient 5 wanted to go to a dealer's house however the officer took her to the hospital. Patient 5 was in Police Protective Custody at this time due to her confusion and inability to care for herself. The report showed they arrived at HRMC at approximately 5:56 PM. The officer waited until Patient 5 was admitted to the ER and, after explaining the situation fully to the ER staff, he left at approximately 7:12 PM.


Review of Patient 5's ED record showed she presented to the ED on 08/05/21 at 6:02 PM escorted by the police department (PD) and Community Mental Health Center Staff, after being found trying to break into people's vehicles, she had gotten into someone's vehicle and then would not get out, so the PD was called. Patient 5 reported some form of drug use that day but was unable to state what she took. Patient 5 exhibited unorganized/random speech and behavior. Her diagnosis was methamphetamine (Meth) intoxication. She denied suicidal ideation (SI) or homicidal ideation (HI) and when asked about hallucinations she stated, yes, laughed, and then would not elaborate any further.

Review of the ED nurses note dated 08/05/21 at 9:01 PM, by Staff M, Registered Nurse (RN) showed, Patient 5 was wanting to leave. The nurse called the phone number written on Patient 5's wrist. There was no answer and unable to leave voicemail. Patient 5 wanted to leave to smoke cigarette. The nurse offered to call other phone numbers, Patient 5 does not know any.

The discharge information dated 08/05/21 at 9:01 PM, by Staff M, RN showed, discharge transportation, other: walking. Patient adamant about leaving.

Patient 5 was discharged from the ED at 9:02 PM, to home/self-care.

Further review of the police report dated 08/05/21 showed "At approximately 2117 Hrs, [9:17 PM] dispatch received a call about a female matching [Patient 5] description and clothing was [sic] asking people for rides. The caller stated they had informed security, but nothing was being done. Due to the lack of time between admittal [sic] and the call, I did not believe that [Patient 5] had been medically cleared or screened by the Crisis Therapist."
The report concluded with, "I do not believe [Patient 5] was able to make decisions regarding her safety effectively however, she had discharge papers from HRMC." [Hutchinson Regional Medical Center].

There was no documented evidence in Patient 5's medical record to show her hallucinations had subsided and her behaviors stabilized before she was discharged out into the community. Within 15-minutes of discharge from the ED, law enforcement was again called related to Patient 5's continued behaviors asking for rides and getting into a vehicle of someone she did not know, placing herself at risk for harm.

During an interview on 09/08/21 at 5:00 PM, Staff AA from the police department stated that there are ongoing concerns with the ED and patients in police protective custody, who have not committed a crime, going back out in the community without mental health screen.

During an interview on 09/03/21 at 8:48 AM, Staff E, ED Medical Doctor (MD), who saw Patient 5 in the ED, stated that Patient 5 was brought in by a plain clothed police officer who works with a social worker from the community mental health crisis team. He stated that he remembers seeing her before for the same thing. Staff E stated that Patient 5 had disorganized thinking, inappropriate laughing and was acting weird. He stated that he didn't have a reason to have her screened (mental health) or make her stay involuntarily (the Physician's ED note showed she had hallucinations and exhibited unorganized/random speech and behavior). He stated that she wanted to leave and that a mental health assessment would have just been going through the motion but would not be enough to make her stay.



Patient 12

Review of Patient 12's EMS patient Care Report dated 08/12/21 at 5:09 PM showed, Patient 12 had a chief complaint of suicidal ideation and pain all over. The history of present illness showed EMS was dispatched to a 47-year-old male for chest pain. Patient 12 had been driving his car in circles in a parking lot. Patient 12 complained of chest pain, suicidal ideation and had drank approximately two fifths of whiskey. The note showed EMS had difficulty getting information from the patient because he kept stating that he wanted to die. EMS assessed Patient 12 and transported him to the hospital.


Review of Patient 12's ED record showed he presented by ambulance on 08/12/21 at 5:46 PM. The ED record showed Patient 5 was witnessed driving in circles in a parking lot and making several statements he wanted to "die" and was hallucinating. The History of Present Illness showed, SI, hallucinations, chest pain and alcohol intoxication. Patient 12 complained of chest pain and pain all over. He reported he was having flashing hallucinations and describes them as delusions. Patient 12 stated that he felt suicidal for two weeks and stated, "I want to die." The Medical Decision Making (MDM) showed the physical examination suggested alcohol intoxication treated with intravenous (IV) fluids, IV thiamin/banana bag (bag of IV fluids containing vitamins and minerals) and further testing revealed positive urine barbiturates (sedative and sleep-inducing drugs) and elevated serum (blood) alcohol. The Clinical Impression showed, Suicidal ideation, Chest pain, Alcohol intoxication, Hallucinations and the provider considered excitatory delirium (a condition that presents with psychomotor agitation, delirium, and sweating) and psychosis (mental disorder). At 7:00 PM on 08/12/21, Patient 12's serum alcohol level was 359 milligrams/deciliter (mg/dL) (range 1.8-20 mg/dL).


Review of Patient 12's ED notes showed that on 08/12/21 at 10:23 PM, Patient 12 was asked if by the unit assistant (UA) if he was able to walk to the bathroom. Patient 12 started yelling obscenities at the Unit Assistant, telling her to die, and that he was agitated so she didn't make him get up.

The record showed a physician's order was written on 08/12/21 at 10:43 PM to discharge Patient 12.

At 10:44 PM documentation showed Patient 12 started pulling his IV out and the UA was unable to stop him.

Discharge documentation showed, Patient 12 was discharged to care of Law Enforcement; Discharge comments showed, Patient 12 continued agitated; speaking over and refusing care. Documentation showed, Paperwork handed to PD (police department). Patient 12 left the ED in police custody at 10:58 PM.

There was no documentation in the medical record of the absence of hallucinations or suicidal ideation to show Patient 12's emergency medical condition was stabilized before he was discharged from the ED.

During an interview on 09/02/21 at 2:15 PM, Staff I, Doctor of Nursing Practice (DNP), Behavioral Health Unit Director stated that patients brought in by law enforcement, who are involuntary, and have charges filed are medically cleared and go back to jail.

During an interview 09/03/21 at 8:05 AM, Staff G, Medical Doctor (MD), ED Medical Director, stated that LE will generally bring in an individual to have them medically cleared before taking them to jail. Some officers stay with the patient in the ED, other times they are dropped off. He stated that when patients arrive at the ED and are exhibiting erratic psychotic behavior, the patients will require a mental health screening. Before a screening is performed, the patient needs to be medically stabilized. Once it is determined there is not a medical emergency, then the ED provider will notify Behavioral Health Unit (BHU) that a mental health exam needs to be conducted. If a patient has been medically cleared, a mental health screening can be done either in the ED by the BHU staff or by the Community Mental Health center in the Jail. If a screening is performed at the jail, and its determined they need inpatient treatment, the LE staff will bring the patient back to the ED for the required lab work to be obtained for admission. He stated that when patients come in intoxicated, on methamphetamine, psychotic; the provider will ensure they are medically stable, order lab work, any diagnostic test needed, and then call for a mental health screening.

Review of a hospital policy titled, "EMTALA Screening & Stabilization" most recently reviewed on October 27, 2020, showed: ...A. Definitions ...Emergency Medical Condition (EMC) means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including ... psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in ...placing the health of the individual in serious jeopardy ... The policy further shows that ...If an EMC exists, HRMC must provide for (i) further medical examination and treatment to stabilize the medical condition within our capability and capacity; or (ii) an appropriate transfer to another medical facility ...