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Based on interview, record review and policy review, the facility failed to follow policy and provide stabilizing treatment within its capacity and capability for one patient (#16) who presented to the Emergency Department (ED) seeking treatment for an emergency medical condition (EMC). Twenty five medical records from August 2018 to February 2019 were randomly selected for review. The facility includes two separate ED campuses with a combined ED average of 8,715 emergency visits per month.

This failure placed all patients presenting to the ED at risk for not receiving treatment to stabilize a potential or actual EMC.

Findings included:

1. Review of the facility's policy titled, "EMTALA Anti-dumping Compliance of Emergency Department and Hospital Patient (Individual) Transfers to Another Facility," dated 11/2012, showed that the facility provides care relating to transfers and discharges that meets or exceeds the specifications of EMTALA. An appropriate medical screening examination (MSE) beyond medical triage will be provided by qualified personnel as determined by the Board of Directors when an individual presents to the ED and requests examination or treatment for a medical condition. When an individual is determined to have an EMC, the facility will provide necessary examination and treatment to stabilize the patient within the capabilities of the staff and facilities available at the hospital and will follow stabilized protocols for appropriate transfer of the patient to another medical facility as indicated or if requested by the patient.

Review of the facility's policy titled, "Triage," dated 04/2018, stated that the purpose of the medical screening protocol is to provide rapid treatment to patients presenting to the ED with certain symptoms and complaints. Consult with the ED physician if additional treatment or further medical intervention is indicated.

Review of the facility's policy titled, "Discharge Against Medical Advice (AMA) or Refusal to Consent to Procedures/Treatment/Surgery," dated 03/2018, establishes the criteria for documentation of patients leaving AMA. The policy stated that all patients indicating the desire to leave AMA shall sign an AMA form and that the registered nurse (RN) and/or physician shall discuss with the patient and/or family, the potential complications that may occur if this patient leaves prior to the physician discharging the patient, document the patient's desire to leave AMA, conversations on potential complications, and the patient's condition prior to leaving the emergency department. Policy also states that patients who lack decision making capacity and request to leave AMA, the nurse should contact the House Supervisor and Risk Management.

Review of Patient #16's medical record showed that following:
- She presented to the ED by Emergency Medical Services (EMS) on 01/28/19 at 6:10 PM with disorganized thinking, (unable to connect thoughts into logical sequence) erratic behavior, (behaving in a wild and unpredictable manner) and altered mental status, (a disruption in how your brain works that causes a change in behavior) and remained in the ED for six hours.
- She was unable to name what state she was in, what city she was in, or who the president was upon presentation. She was unable to provide medical staff details and stated, "I don't know" when asked further questions.
- She was triaged at 6:28 PM with no active medical problems displayed, at an acuity level of 2 (an algorithm used to determine urgency with 1 being the most urgent and 5 being the least urgent). She would not speak with any male officers, or ED staff, and was only willing to speak with female staff.
- A drug screen showed Cannabinoids (chemical compounds that are the active principles of marijuana) was detected.
- She received a MSE at 7:33 PM that showed the patient did not seem intoxicated or under the influence of any drugs, and that she appeared scared and timid. She was placed on elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury).
- She denied any sexual abuse. However, medical staff were concerned for possible trafficking (the recruitment, transportation, transfer, harboring or receipt of persons, by means of threat or use of force for the purpose of exploitation) and therefore notified the Sexual Assault Response Team (SART) at 7:33 PM.
- She repeatedly denied sexual or physical abuse. Staff J, Nurse Practitioner (NP) documented, "suspected mental health disorder" as the cause of Patient #16's symptoms.
- Law enforcement and the SART left the ED at 8:57 PM, due to Patient #16's continued denial of any physical or sexual abuse.
- A Behavioral Health Exam (BHE) was conducted on 01/28/19 at 10:30 PM and documentation showed that the patient did not meet involuntary admission criteria.
- Staff J, NP, re-evaluated Patient #16 at 10:33 PM and documented that she was alert and oriented (A&O, person is alert and orientated to person, place, time, and situation) and had shown improvement since previous evaluation. Staff J recommended a voluntary admission for further psychiatric evaluation. Patient #16 agreed to voluntary admission.
- On 01/29/19 at 12:30 AM, Patient #16 refused further evaluation and treatment and no longer agreed to voluntary admission. Staff J, NP explained the risks of leaving AMA to the patient (#16) and her mother. Both agreed to risks.
- On 01/29/19 at 12:35 AM Patient #16 was discharged AMA to return home with her mother.

During an interview on 02/07/19 at 11:30 AM, Staff J, NP, stated that when Patient #16 arrived at the ED she was unstable, disorganized in thought, withdrawn and timid. Her demeanor and awareness changed drastically when her mother arrived, and she became more alert, verbal and communicative with staff. She denied suicidal ideation (SI) and homicidal ideation (HI). Staff J recommended further psychiatric evaluation and a voluntary admission. When Patient #16 refused the voluntary admission, Staff J spoke with patient #16's mother regarding the affidavit process, in which Staff J stated that the mother was knowledgeable on. The patient's mother declined completing an affidavit, so Staff J educated Patient #16 and her mother of the risk of leaving AMA. Patient #16 and her mother verbalized understanding of AMA risk and chose to discharge AMA. Staff J verbalized she did not feel as if the patient was a threat to herself or others and was capable of making her own decision at time of discharge.

During an interview on 02/20/19 at 1:00 PM, Staff K, Master in Social Work (MSW), stated that House Supervisor and Risk Management were not contacted because it had been determined that Patient #16 did not lack decision making capacity.

Patent #16 presented to a Hospital B's (nearby hospital) ED on 01/29/19 at 6:24 PM, approximately 18 hours after discharge, with suspected substance abuse, and erratic and odd behavior. Her mother did complete an affidavit at this location, and Patient #16 was admitted voluntarily for inpatient behavioral health services with a diagnosis of Unspecified schizophrenia spectrum and other psychotic disorders (a disorder characterized by psychotic [false ideas about what is taking place or who one is] and mood disturbance [a prominent and persistent disturbance in mood]).

Please refer to the 2567 for details.

Based on interview, record review and policy review, the hospital failed to provide within its capabilities, stabilizing treatment prior to discharging one patient (#16) who presented to the hospital emergency department (ED) seeking care for an emergency medical condition (EMC) out of a sample of 25 discharged records selected from August 2018 through February 2019. The facility includes two separate ED campuses with a combined ED average of 8,715 emergency visits per month.

Findings included:

Review of the facility's policy titled, "EMTALA Anti-dumping Compliance of Emergency Department and Hospital Patient (Individual) Transfers to Another Facility," revised 07/2017, showed that:
- An appropriate medical screening examination beyond medical triage will be provided to an individual when they present to the ED and request examination or treatment for a medical condition.
- An EMC is defined as a medical condition which manifests itself with acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse [inappropriate use of drugs or alcohol]symptoms) 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 to any bodily functions or serious dysfunction of any bodily organs or part.
- Once an EMC is identified, the hospital must provide either further examination or treatment required to stabilize the EMC or transfer the individual to another medical facility that provides the treatment required.
- If at any time an individual refuses to consent to examination or treatment, the hospital shall take the necessary steps to obtain written informed refusal and document in the medical record the wishes of the patient to refuse treatment.

Review of Patient#16's ED record dated 01/28/19 at 6:10 PM, showed that:
- A 22 year old female arrived to the ED via EMS;
- Law enforcement and EMS arrived to the scene to find that she had driven a vehicle not registered to her into a driveway that was not hers, and then walked away;
- She did not make any sense while on the scene, so EMS transported her to the ED for evaluation;
- She was able to state her name, date of birth, and the current year;
- She was not able to state what city or state she was in, nor who the current president was;
- When asked about where she lived, she stated, "I do not know";
- She stated that she had been doing a lot of walking lately, and stayed in a house with "so many people", but was unable to state where that home was located, or how long she had been staying there;
- She denied any sexual or physical abuse;
- Denied any suicidal ideations (SI, thoughts to harm self) or homicidal ideations (HI, thoughts to harm others);
- She denied any alcohol or drug usage that day;
- She continued to refuse to speak with any male law enforcement or ED staff;
- Multiple labs were collected, including a urinalysis and a urine drug screen.
- At 7:33 PM, local law enforcement had been notified of potential sexual or physical abuse of Patient #16, due to her behaviors. She was reluctant to answer questions, timid, and refused to speak with male caregivers. That caused concern about possible sex trafficking (the recruitment, transportation, transfer, harboring or receipt of persons, by means of threat or use of force for the purpose of exploitation). The Human trafficking hotline was notified. The Sexual Assault Response Team (SART) was notified.
- At 7:52 PM, she repeatedly denied any sexual or physical abuse. The concern then focused on possible mental health disorder. She was only orientated times two, unable to make informed decisions, and placed on elopement precautions (interventions to prevent someone from leaving who may be at risk for self-harm or injury).
- At 8:57 PM, local law enforcement and the SART team left. The patient had continued to deny any sexual or physical abuse. Her mother was at the bedside and shared that the patient had a history of panic attacks (specific periods of sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom).
- At 10:30 PM, Mental Health Services Intake Assessment was completed. It was determined that Patient #16 did not meet involuntary admission criteria.
- At 11:33 PM, Patient #16 was reevaluated and found to be alert and orientated. She was able to state her name, date of birth, year, president, location, and current city. She continued to deny any SI or HI. She continued to exhibit signs of paranoid (paranoia, excessive suspiciousness without adequate cause) behavior, refused to go to the bathroom alone, and refused to speak with male staff. Patient #16 was agreeable to being admitted voluntarily at that time. Her mother voiced concerns about taking her home with the continued disorganized thinking (unable to connect thoughts into logical sequence). She then provided further history of Patient #16 being diagnosed and hospitalized in August 2017 with an adjustment disorder (an abnormal and excessive reaction to an identifiable life stressor; involves a feeling sadness and hopeless; having a hard time coping with change).
- At 11:40 PM, the urine drug screen was reviewed and showed that she was positive for cannabinoids (chemical compounds that are the active principles of marijuana).
- At 11:43 PM, Patient #16 was alert and orientated. Elopement precautions were removed.
- At 12:30 AM on 01/29/19, Patient #16 refused to stay for further work up or treatment. She stated she wanted to go home. She remained alert and orientated, and continued to deny SI or HI. The intake mental health professional determined that she did not meet criteria for involuntary admission. Patient #16 wanted to discharge to home, and planned to stay with her mother. Psychiatric resources were provided. AMA risks explained to the patient, and she voiced that she understood and was agreeable. Patient #16 was then instructed to return to the ED if she changed her mind about the voluntary admission. Both the patient and mother verbalized understanding.
- Patient #16 did leave against medical advice. Her diagnoses were listed as: Disorganized Thinking, Paranoia, and Urinary Tract Infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra).

Review of Patient #16's Mental Health Assessment dated 01/28/19 at 10:30 PM, showed that:
- Patient #16 presented to the ED via EMS with bizarre behavior and inability to answer questions appropriately.
- She had previous mental health inpatient admission in 2017.
- She denied suicidal ideation, self- mutilation, violent behavior, and homicidal ideation.
- Her mood symptoms included anhedonia (an inability to experience pleasure from activities usually found enjoyable) and "Sometimes I don't care a lot."
- She denied delusions (false ideas about what is taking place or who one is, despite evidence to the contrary), paranoia, and hallucinations (seeing or hearing things which aren't there).
- She denied anxiety (fear and worry are constant and overwhelming), a traumatic experience, or any abuse.
- Her appearance was appropriate, she was alert and orientated, and her thought process was coherent.
- Her affect was guarded, and her speech was slow or latent.
- She denied any suicidal thought or a wish to be dead when the Columbia Suicide Severity Rating Scale (a questionnaire used for suicide risk assessment) was completed.
- The diagnosis was an unspecified mood/affective disorder (a group of psychiatric disorders with three main types, depression [a long period of feeling worried or empty with a loss of interest in activities once enjoyed], bipolar [a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks]), and anxiety. And Patient #16 did not meet inpatient criteria.

During an interview on 02/04/19 at 3:25 PM, Staff A, Registered Nurse (RN), Christian Northeast ED Department Manager, stated that Social services were stationed in the ED Monday through Friday from 9:00 AM to 5:00 PM, to provide assistance with psychiatric intake. A social service psychiatric intake person was available 24 hours a day, they may physically come to the ED, or may use telepsychiatry (telepsych, physician or health care provided psychiatric assessment and care through a camera and video monitor, while the health care provider is at a separate location) capability for patient triage.

During an interview on 02/05/19 at 10:32 PM, Staff G, RN, Christian Northwest ED Department Manager, stated that a social service psychiatric intake staff member was available 24 hours a day, and sometimes came to the ED or used telepsych for patient triage. A nurse practitioner may be assigned a psychiatric patient, but it was extremely rare, and if it happened, a physician remained in the ED 24 hours a day, seven days a week, to supervise.

During an interview on 02/05/19 at 10:49 AM, Staff H, Medical Doctor (MD), Medical Director for the Northwest Campus ED, stated that a physician was responsible for completion of the initial MSE, which included the History and Physical and any laboratory testing or radiological testing. For a psychiatric patient, the initial MSE would include evaluation by a specialty trained intake coordinator. The MD and the intake coordinator were always in contact with each other for ease of communication.

During a phone interview on 02/07/19 at 11:30 AM, Staff H, MD, Medical Director for the Northwest Campus ED, stated that the Columbia Suicide Severity Rating Scale would be utilized for every mental health assessment completed.

During a phone interview on 02/07/19 at 11:30 AM, Staff J, NP, stated that she was not initially assigned to Patient #16, the male MD on duty was, but due to the patient's reluctance to interact with male staff members, they changed the provider. During the early assessment of Patient #16, staff felt that there were concerns with possible sexual or physical assault, and her reluctance to answer any questions. Once male staff members were removed, Patient #16 began to answer questions appropriately. There was a noticeable difference once the patient's mother arrived at the bedside; she became much more forthcoming with her answers. Staff J, spoke with mental health intake staff twice during Patient #16's ED visit and both times she was informed that Patient #16 did not meet involuntary admission criteria. Typically a patient must be suicidal or homicidal in order to involuntarily hold them. She discussed completion of an affidavit (a written statement confirmed by oath that it is true) with the patient's mother, due to Patent #16's paranoid behavior, but the mother declined. The patient's mother voiced that she had felt an affidavit was not necessary, and the patient wanted to go home. The mother worked as a psychologist in a mental health clinic, and was therefore familar with and appeared knowledgeable with the use of an affidavit to hold a patient. She had Patient #16 sign an AMA document because her assessment concluded that the patient would benefit from further assessment on a voluntary psychiatric admission. Patient #16 was able to make informed decisions and was not suicidal or homicidal upon discharge.

During an interview on 02/20/19 at 1:00 PM, Staff K, Masters of Social Work (MSW), stated that:
- A Mental Health Professional (MHP) was available 24 hours a day, seven days a week, for consult in the ED.
- The MHP could be a MSW, Licensed Professional Counselor (LPC), or a Registered Nurse (RN) with mental health training.
- The MHP collaborated with the ED provider to determine if a psychiatric EMC existed for the patient.
- To determine if a patient met criteria for an involuntary (done against someone's will) admission, the patient would have to be suicidal with a plan, homicidal with homicidal ideations, or exhibit signs of psychosis that would deem them to be impaired or unsafe.
- When she spoke with Staff J, NP, they determined that Patient #16 did not meet involuntary admission criteria.
- She had concerns that Patient #16 could have been under the influence of some type of substance, due to her initial bizarre behavior, but her drug screen failed to indicate any substances other than cannabinoids.
- The providers in the ED's have seen an increase in bizarre behaviors related to substances that did not show up on drug screens.
- Patient #16 did not exhibit any of the initial behaviors she had presented with. Had she seen any indication of bizarre behavior or disorganized thought during the psychiatric assessment, there would have been a different outcome.
- The Hospital Supervisor and Risk Manager were not contacted as directed in the AMA policy because it was determined that the patient did not lack decision making ability.

Documentation in the medical record showed that the facility failed to stabilize Patient #16's EMC prior to discharge. She was allowed to leave the facility with continued paranoia and disorganized thinking. The patient presented to the Hospital B ED (a nearby hospital) approximately 18 hours after discharge with an emergency medical condition. Patient #16's mother completed an affidavit at that time. These events resulted in a voluntary inpatient psychiatric admission.



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