HospitalInspections.org

Based on medical record reviews, central logs, policies and procedures and staff interviews, the emergency department hospital staff failed to utilize resources within the hospital's capability in a Dedicated Emergency Department (DED) to address an emergency psychiatric condition for one of 24 medical records reviewed (Patient #1).

Findings included ...

Record review of the hospital's policy titled, "Emergency Medical Condition Evaluation, Treatment, and Transfer (EMTALA), dated 7/10/2019, showed that an Emergency Medical Condition (EMC) - means a medical condition with symptoms of sufficient severity (including severe pain, psychiatric disturbances, and or symptoms of substance abuse) such that without immediate medical attention the patient can be expected to experience: 3.1- Serious impairment to any bodily functions including mental impairment; or 3.2- Serious impairment to any bodily functions including mental impairment; or 3.2-Serious dysfunction of any bodily organ or part including mental dysfunction .... Medical Screening Examination (MSE)- means the process for determining with reasonable clinical confidence, whether or not an EMC exists. This is documented in the patient's medical record ... Stabilize- Means to provide the medical treatment, within the Hospital's capabilities, as may be necessary to assure that no material deterioration of the EMC is likely to result from or occur during the transfer of a patient to another facility or upon discharge of the patient from the hospital. Responsibilities: Patient Evaluation and Treatment- 1.1 Medical Screening Examination- 1.1.1- Every individual who presents on Hospital Property ( DED (Dedicated Emergency Department or other than the DED) and who request examination or treatment for a medical condition (or has such request made on his/her behalf), must be offered a MSE (Medical Screening Examination) within the Hospital's capability, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists ..."

Patient #1 presented to the Emergency Department on March 17, 2021, at 19:55 (7:55 PM), under the custody of Law Enforcement and an FD-12 for a psychiatric evaluation.

According to hospital policy titled, Management of Patients Leaving by Elopement or AMA (Against Medical Advice), dated 03/11/2020, FD-12 is defined as: A behavioral health government form used to bring a patient to the hospital for evaluation.

According to Employee #12, Registered Nurse, triage note dated 3/17/2021 at 8:11 PM, showed Patient #1 presented with a chief complaint of, "Pt (Patient) in custody needing medical clearance. Pt has no complaints at this time."

The patient's Emergency Severity Index was 4, which requires the registered nurse to complete a focused assessment detailing pertinent information base on the patient's chief complaint to include the following: Pain Glasgow coma scale, Social History, General, Morse fall risk, Allergies and Safety Screen." . The patient's neurological assessment showed him alert, responsive, with auditory hallucinations present.

Record review of the hospital policy titled, "Suicide Risk Assessment,", dated 10/09/2019, stipulates; " ... VIII. SCREENING and RISK MITIGATION PROCEDURE: NON-DEDICATED SPACE(S) A. Emergency Department: 1. All persons presenting to the Emergency Department (ED) with a primary complaint and/or diagnosis of an emotional, behavioral, or psychiatric disorder will be screened using the CSSR-S ..."

The Triage nurse did not perform a CSSR (Columbia Suicide Severity Rating Scale) on the patient. The rating scale screen is performed in triage to evaluate or treat patients with behavioral health conditions as their primary reason for care, express suicide ideation or are deemed by their provider to be at risk for self-harm. There was no "medications reconciliation" documented. The registered nurse documented that the patient had a presence of secondary diagnosis.
The ED (Emergency Department) physician, Employee #7, examined Patient #1 on 3/17/2021 at 8:29 PM. The history and physical showed that the patient had a history of Schizophrenia, was formerly on Abilify and Seroquel; and had been off medications for some time. Further documented, that the patient was "bought in under arrest by MPD (Metropolitan Police Department) for psych eval. Was originally brought to CPEP (Comprehensive Psychiatric Emergency Program) who declined to evaluate him; and he was sent here [hospital ED]. Patient has a mental health warrant for emergency detention issued [city and state named where patient traveled from] dated 3/12/21. .... Answers basic questions but quite tangential. Says he isn't sure how he got here." After the physician performed the physical examination, he documented the following assessment and plan: [Patient #1] "under arrest with Police Department and was requesting psychiatric evaluation. [Patient #1] was taken to CPEP who declined. Will get Covid swab, discussed with psych here but they do not evaluate people under arrest and patient will likely have to go back to CPEP ...Unable to do psych eval at this facility given that he is under arrest, will release to custody."

A physician order dated 03/17/2021 at 20:34 (8:34 PM) directed, COVID-19/Coronavirus PCR -Nasopharyngeal Swab, STAT collect. However, the order was discontinued on 03/20/2021 at 21:02 (9:02 PM), with physician co-signing as "not required."

The medical record lacked documentation of any further diagnostic workup to evaluate the patient. Additionally, there was no evidence that a COVID swab was obtained from the patient during the time frame of 32 minutes before discontinuing the physician order.

According to the "Final Report," dated 03/17.2021 at 23:08 (11:08 PM), Employee #12, documented that Patient #1 was in Metropolitan Police custody for medical clearance. Patient #1 had no complaints at the time and stated he has a history of hypothyroidism. Further stated he was once on Abilify and Seroquel but no longer takes them. Patient #1 informed the registered nurse that "he hears unique whispers. Patient #1 was also stating about "3 stones" and asking the police to investigate it. At 21:00: Employee #13, documented, "Pt medically clear for incarceration. Pt given discharge information with this RN reviewing all documents with pt. Pt verbalized understanding of the information presented and this RN answered all questions pt had. Pt has all belongings with them. Pt in no apparent distress, VSS (Vital Signs Stable), ready for discharge."

A review of the medical record showed a "Patient Visit Summary," signed by Employee #12, Registered Nurse, dated 3/17/2021 at 2100 (9:00 PM), stating the patient had received patient education materials and instructions and have verbalized understanding. "Pt (Patient) in Custody" was printed on the Patient/Patient Representative Signature line. Diagnoses: "Evaluation by psychiatric service required."

A review of Patient #1's discharge instructions showed the physician discharged him on 3/17/2021 at 23:10 (11:10 PM) to law enforcement detention. Written under information about hospital visit, Diagnoses: "Evaluation by psychiatric service required." The physician prescribed no medications on discharge.

The attending emergency department physician did not consult a psychiatrist for assistance in screening and stabilization of the patient psychiatric medical condition. The physician discharged the patient without a psychiatric evaluation, in accordance to his documentation, the patient still required a psych evaluation.

The patient, who presented to a dedicated emergency department, did not receive a psychiatric evaluation or treatment by available Psychiatrists or Behavioral Health Clinicians, subsequently the patient did not get stabilized treatment before being discharge with the Metropolitan Police Department. The patient was in the emergency department for 3 hours and 15 minutes, from his time of arrival to discharge.

The surveyors conducted a face-to-face interview with Employees #4, Vice-Chair of Emergency Medicine, and Employee #5, Nursing Director of Emergency Department on 03/22/2021 at approximately 2:30 PM, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12. Both stated that they do the initial screening. There is a two-step process- medical and psychiatry, to include stabilization of the patient. Further said that they have a policy related to the exclusion of patients under law enforcement custody, requiring psychiatric evaluations. However, it is case-specific. They complete a safety risk assessment on the patient to ensure there is no harm to self and others. The ED staff evaluates patients in the emergency department for transfer to a forensic facility for a psych evaluation. Both stated that if further evaluation is needed, they can utilize inpatient behavioral health services.

The surveyors conducted a face-to-face interview with Employee #6, Attending Psychiatrist, on 03/22/2021 at approximately 3:00 PM, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12. He stated they would evaluate patients; however, it depends on the medical exam-the emergency department physician requests psychiatry to be consulted. If consulted, they will evaluate the patient. He further stated, he was on-call on 03/17/2021; however, he did not receive a call relative to a patient in custody and FD-12, who needed a psych consult.

The surveyors conducted a face-to-face interview with Employee #7, Attending Emergency Department Physician, on 3/22/2021 at approximately 3:40 PM, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12. He stated they do not do psych evaluations when patients are under arrest. Further said, the person under arrest goes to CPEP for psych evaluations. However, we do a medical examination. In the case of Patient #1, he stated CPEP denied the patient; because he traveled from a high-risk COVID- state; and needed COVID clearance. Also, the patient was an FD-12 and needed a psych evaluation. He stated he called the "Psych." He spoke to a Behavioral Health Social Worker, who does Behavior Health Assessments, to clarify the policy regarding patients under arrest who needs a psychiatric evaluation. The Social Worker confirmed what he thought the policy meant, that they do not do psych evaluations on patients presenting to ED (Emergency Department) under arrest. When queried, "If the [Patient #1] needed a psych evaluation, he stated, "Yes." When the surveyor asked about the COVID-testing, he stated that MPD could not wait when he informed them that the wait time for the results would be two hours.

The surveyors conducted a face-to-face interview with Employees #8, Executive Director for Behavioral Health, and Employee #9, Director, LICSW (Licensed Social Worker) for Behavior Health Intake Assessments 03/22/2021, at 4:07 PM. The interview regarded their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12. They said they could not admit patients under arrest to the behavioral health units. They are transferred to CPEP or other forensic facilities if they require inpatient admission. However, if the emergency department notifies them that a patient under arrest needs an evaluation, they will see the patient.

The surveyors conducted a virtual face-to-face interview with Employee#10, Director of Behavioral Medicine, on 03/31/2021, at approximately 12:05 PM, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12.
She voiced that she just learned about the incident, which occurred in the ED on 03/17/2021. She said she received an email from CPEP's Medical Director about the patient.

She said CPEP did not inform them of the patient's [Patient #1] pending arrival to the emergency department. However, the patient did have a psychiatric illness, and he needed admission; the last question-where the patient needed to be admitted. Further stated that they [Behavioral Health Department] did not receive a call to evaluate the patient in the emergency department. If the ED consulted them, we would have completed the evaluation.


The surveyors conducted a virtual face-to-face interview with Employee#11, Director of Emergency Medicine, on 03/31/2021, at approximately 12:05 PM, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody and FD-12. The emergency department physicians are capable of evaluating patients with psychiatric conditions. The patient [Patient #1] had a medical screening exam, including psych evaluation. The process was not complete because the law enforcement officers' left with the patient. The process included the COVID- 19 swabs and transferring the patient to a psychiatric facility.

The surveyors conducted a virtual interview with Employee# 12, Registered Nurse, Triage, on 03/31/2021, regarding their process of evaluating patients who present to the emergency department with psychiatric medical conditions under law enforcement custody with an FD-12 at approximately 1:15 PM. When queried about her documentation regarding; medical clearance as the chief complaint for Patient #1, she stated that the forms presented to her by the police officers' included a "313 Form", a medical clearance for incarceration, and to be released back to law enforcement. Also, she stated an FD-12 form and paperwork from another state for the patient for evaluation.

When the surveyor asked, how was Patient #1's behavior in triage? She stated, "He was calm, cooperative, polite, and sitting quietly. However, he was having auditory hallucinations. He kept talking about "3 stones that sent him there." Employee #12 stated the attending emergency department physician called the on-call Psych Social Worker. She interpreted the conversation between the social worker and attending as psych could not do a psych evaluation if the person is under arrest at this facility. She further stated that the oncoming police officers called CPEP and asked if the patient tested negative for COVID-19; could the patient return to CPEP. They responded that only the Director could answer that question; she had left for the day. The police officer did not want to wait for the results. She stated the patient sat in the triage room for over one hour after being discharged; they were trying to decide where to transport the patient.