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Based on interview and record review the CAH failed to provide an appropriate Medical Screening Exam (MSE) to determine whether an Emergency Medical Condition (EMC) existed for 1 of 23 applicable patients (Patient #1) who arrived via ambulance to the Emergency Department (ED) intoxicated with suicidal ideations, was discharged, and then transferred by non-medical personnel (law enforcement) to a facility. Findings include:

Per review of the Emergency Response Service (EMS) report, on 11/4/19 at 11:36 PM, the regional ambulance service responded to a call for a suicide attempt involving Patient #1. Patient #1 was assessed by EMS and transported to the nearest hospital ED, arriving at 12:29 AM on 11/5/19.

Per review of nursing notes on 11/5/19 at 12:33 AM, the nurse performed an Ask Suicide-Screening Questions (ASQ) Suicide Screening of Patient #1, the screen was positive, and the nurse noted in the record that the provider was notified. At 12:40 AM the patient showed evidence of alcohol intoxication, s/he reported ingestion of narcotics, and had suicidal ideation. The state police had followed the ambulance to the hospital and "a police breathalyzer showed an alcohol level of 190". The patient was agitated, anxious and smelled of alcohol. S/he was alert and oriented to person, place and time. His/her gait was steady, and speech slurred. The patient was unsettled and threatening staff and other patients while in the ED. The patient requested to go outside to smoke. The nurse along with local police, state police, and hospital security escorted the patient outside to smoke. The patient was then discharged and taken by the state police. Per the record the discharge was ordered at 12:59 AM.

Per review of a physician's progress note from 11/5/19 at 1:38 AM Patient #1 had a history of alcohol abuse and suicidal ideation. S/he was "brought in by police because of suicidal ideation". S/he was very agitated and threatening to staff and other patients. The physician's exam at 1:41 AM revealed the following: "Behavior/mood is agitated, Affect is animated, Patient having thoughts of suicide". At 1:43 AM "The patient appears agitated, alert. Exam negative for motor deficits. Unable to obtain exam due to patient being uncooperative". At 1:44 AM, the physician's note read, "Agitated and intoxicated patient. Patient is having thoughts of self-harm but unable to be assessed by counseling service until" s/he "is sober". S/he "is currently very agitated and is unsafe in our department". S/he "is going to be taken by the police to an observation unit". S/he "will be assessed by us counseling service once" s/he "is sobered up".

Per interview on 1/7/20 at 8:06 AM with the treating ED Physician, s/he stated that his/her usual practice with a patient who comes into the ED intoxicated with suicidal ideations was that the patient would be put on one to one monitoring with a staff member, would be closely observed, and would typically stay in the ED approximately six to eight hours. S/he stated that s/he would perform an initial assessment of the patient and then when the patient sobered up s/he would re-examine the patient and counseling services would be contacted so they could evaluate the patient and recommend that the patient be discharged home with a safety plan and/or be admitted to inpatient psychiatric facility. Regarding the case with Patient #1, s/he stated that s/he was busy with another patient and heard the call from EMS on the ED scanner. S/he stated that when s/he first went into the room the patient was angry, loud, aggressive and "obviously intoxicated". S/he stated that the patient did not exhibit any "respiratory issue" and "protected" his/her "airway". S/he stated that "in my mind" s/he "could go to a place to sober up". S/he stated that s/he "knows counseling will not evaluate a patient if the patient was intoxicated". S/he stated that the patient was very "agitated", and s/he was "looking at chemical and physical restraints and did not want to do this". S/he stated that s/he "had in mind police could keep the patient safe and that there was a facility to keep patients until they sobered up". S/he confirmed that s/he "would consider suicidal ideation a medical emergency"; and that "we should have kept the patient until sober".

Per interview with the ED Medical Director on 1/7/20 at 1:34 PM, s/he stated that a medical screening exam meant that "I have laid eyes on the patient" and if they "don't have an acute medical condition, can leave the room". S/he stated that "suicidality is not an emergency condition" and that s/he "did not believe it was an acute medical condition in the EMTALA regulations".

Per review of the policy "EMTALA Guidelines"-approved 11/2019, it read that an EMC is "A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk. A MSE is "The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The process may range from a simple examination (brief history and physical) to a complex examination that may include laboratory tests, other diagnostic testing, and the use of on-call specialists."

Per review of the policy "Psychiatric Patients in the Clinical Areas"-approved 11/2019 it read, "A. During triage, nursing staff will screen every patient for suicidal/homicidal ideation. All patients exhibiting behavior or verbalizing harm to self or others will be evaluated promptly, risk level assessed, emergency treatment and crisis intervention provided in conjunction with the Counseling Service ... ......Hospital Medical Staff. D. All patients will be considered high risk until the evaluation is completed. G. The patient will be processed in the same manner as any patient to be seen in the ED to include a nursing and ED physician assessment."

Based on interview and record review the CAH failed to provide further medical examination and stabilizing treatment within the capabilities of the staff and facilities available in the hospital for an emergency medical condition prior to discharge and/or transfer for 1 of 23 applicable patients (Patient #1). Findings include:

Per review of the Emergency Response Service (EMS) report, on 11/4/19 at 11:36 PM, the regional ambulance service responded to a call for a suicide attempt involving Patient #1. Patient #1 was assessed by EMS and transported to the nearest hospital ED, arriving at 12:29 AM on 11/5/19.

Per review of nursing notes on 11/5/19 at 12:33 AM, the nurse performed an Ask Suicide-Screening Questions (ASQ) Suicide Screening of Patient #1, the screen was positive, and the nurse noted in the record that the provider was notified. At 12:33 PM, the patient's vital signs were blood pressure 132/87, pulse 130, and respirations 20. At 12:40 AM the patient showed evidence of alcohol intoxication, s/he reported ingestion of narcotics, and had suicidal ideation. The state police had followed the ambulance to the hospital and "a police breathalyzer showed an alcohol level of 190". The patient was agitated, anxious and smelled of alcohol. S/he was alert and oriented to person, place and time. His/her gait was steady, and speech slurred. The patient was unsettled and threatening staff and other patients while in the ED. The patient requested to go outside to smoke. The nurse along with local police, state police, and hospital security escorted the patient outside to smoke. The patient was then discharged and taken by the state police. Per the record the discharge was ordered at 12:59 AM.

Per review of a physician's progress note from 11/5/19 at 1:38 AM Patient #1 had a history of alcohol abuse and suicidal ideation. S/he was "brought in by police because of suicidal ideation". S/he was very agitated and threatening to staff and other patients. The physician's exam at 1:41 AM revealed the following: "Behavior/mood is agitated, Affect is animated, Patient having thoughts of suicide". At 1:43 AM "The patient appears agitated, alert. Exam negative for motor deficits. Unable to obtain exam due to patient being uncooperative". At 1:44 AM, the physician's note read, "Agitated and intoxicated patient. Patient is having thoughts of self-harm but unable to be assessed by counseling service until" s/he "is sober". S/he "is currently very agitated and is unsafe in our department". S/he "is going to be taken by the police to an observation unit". S/he "will be assessed by us counseling service once" s/he "is sobered up".

Per interview on 1/7/20 at 9:08 AM with the treating ED Nurse, s/he stated that Patient #1 presented to the ED intoxicated and belligerent. S/he stated that s/he had taken care of Patient #1 in the past and that s/he had behavioral issues when intoxicated; however, when "sober was pleasant and remorseful". S/he stated that Patient #1 was "endorsing suicidal ideations and narcotic overdose". S/he stated that s/he was able to hook the patient up to the monitor and get a set of vital signs. S/he stated the ED was very busy at the time and the patient started to "ramp up". The nurse stated that s/he tried to de-escalate the patient and that those efforts were not working. The patient constantly asked to have a cigarette. S/he stated that s/he took the patient outside to have a cigarette with the thought that it would help to calm him/her down. S/he and the patient were accompanied by local police, state police, and security who were already present in the department. S/he stated that the patient was "amenable to the plan" of going back inside the building and taking a medication for anxiety. S/he stated that two or three of the police officers in the department were discussing the patient's disposition with the physician. S/he stated that the local police notified him/her that the patient was "discharged" and then the "situation left my hands". S/he stated that s/he "did not have time to give the physician a verbal report of the patient's presentation" and that the "physician and nurse almost had no transfer of information" while the patient was in the ED.

Per interview on 1/7/20 at 8:06 AM with the treating ED Physician, s/he stated that his/her usual practice with a patient who comes into the ED intoxicated with suicidal ideation's was that the patient would be put on one to one with a staff member, would be closely observed, and would typically stay in the ED approximately six to eight hours. S/he stated that s/he would perform an initial assessment of the patient and then when the patient sobered up s/he would re-examine the patient and counseling services would be contacted so they could evaluate the patient and recommend that the patient be discharged home with a safety plan and/or be admitted to inpatient psychiatric facility. Regarding the case with Patient #1, s/he stated that s/he was busy with another patient and heard the call from EMS on the ED scanner. S/he stated that when s/he first went into the room the patient was angry, loud, aggressive and "obviously intoxicated". S/he stated that the patient did not exhibit any "respiratory issue" and "protected" his/her "airway". S/he stated that "in my mind" s/he "could go to a place to sober up". S/he stated that s/he "knows counseling will not evaluate a patient if the patient was intoxicated". S/he stated that the patient was very "agitated", and s/he was "looking at chemical and physical restraints and did not want to do this". S/he stated that s/he "had in mind police could keep the patient safe and that there was a facility to keep patients until they sobered up". S/he confirmed that s/he "would consider suicidal ideation a medical emergency"; and that "we should have kept the patient until sober".

There was no evidence in the record that Patient #1 with suicidal ideation was assessed by the counseling service to determine whether s/he would be safe to discharge and/or would need hospitalization. The patient was discharged to non-medical personnel (law enforcement) prior to receiving stabilization and/or discharge/transfer instructions.

Per review of the policy "EMTALA Guidelines"-approved 11/2019 it read, "Stabilize: No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition."

Based on interview and record review the CAH failed to provide an appropriate transfer and/or discharge of a patient with an Emergency Medical Condition (EMC) with qualified medical personnel for 1 of 23 applicable patients (Patient #1). Findings include:

Per review of the Emergency Response Service (EMS) report, on 11/4/19 at 11:36 PM, the regional ambulance service responded to a call for a suicide attempt involving Patient #1. Patient #1 was assessed by EMS and transported to the nearest hospital ED, arriving at 12:29 AM on 11/5/19.

Per review of nursing notes on 11/5/19 at 12:33 AM, the nurse performed an Ask Suicide-Screening Questions (ASQ) Suicide Screening of Patient #1, the screen was positive, and the nurse noted in the record that the provider was notified. At 12:40 AM the patient showed evidence of alcohol intoxication, s/he reported ingestion of narcotics, and had suicidal ideation. The state police had followed the ambulance to the hospital and "a police breathalyzer showed an alcohol level of 190". The patient was agitated, anxious and smelled of alcohol. S/he was alert and oriented to person, place and time. His/her gait was steady, and speech slurred. The patient was unsettled and threatening staff and other patients while in the ED. The patient requested to go outside to smoke. The nurse along with local police, state police, and hospital security escorted the patient outside to smoke. The patient was then discharged and taken by the state police. Per the record the discharge was ordered at 12:59 AM.

Per review of a physician's progress note from 11/5/19 at 1:38 AM Patient #1 had a history of alcohol abuse and suicidal ideation. S/he was "brought in by police because of suicidal ideation". S/he was very agitated and threatening to staff and other patients. The physician's exam at 1:41 AM revealed the following: "Behavior/mood is agitated, Affect is animated, Patient having thoughts of suicide". At 1:43 AM "The patient appears agitated, alert. Exam negative for motor deficits. Unable to obtain exam due to patient being uncooperative". At 1:44 AM, the physician's note read, "Agitated and intoxicated patient. Patient is having thoughts of self-harm but unable to be assessed by counseling service until" s/he "is sober". S/he "is currently very agitated and is unsafe in our department". S/he "is going to be taken by the police to an observation unit". S/he "will be assessed by us counseling service once" s/he "is sobered up".

Per interview on 1/7/20 at 9:08 AM with the treating ED Nurse, s/he stated that Patient #1 presented to the ED intoxicated and belligerent. S/he stated that s/he had taken care of Patient #1 in the past and that s/he had behavioral issues when intoxicated; however, when "sober was pleasant and remorseful". S/he stated that Patient #1 was "endorsing suicidal ideation and narcotic overdose". S/he stated that s/he was able to hook the patient up to the monitor and get a set of vital signs. S/he stated the ED was very busy at the time and the patient started to "ramp up". The nurse stated that s/he tried to de-escalate the patient and that those efforts were not working. The patient constantly asked to have a cigarette. S/he stated that s/he took the patient outside to have a cigarette with the thought that it would help to calm him/her down. S/he and the patient were accompanied by local police, state police, and security who were already present in the department. S/he stated that the patient was "amenable to the plan" of going back inside the building and taking a medication for anxiety. S/he stated that two or three of the police officers in the department were discussing the patient's disposition with the physician. S/he stated that the local police notified him/her that the patient was "discharged" and then the "situation left my hands". S/he stated that s/he "did not have time to give the physician a verbal report of the patient's presentation" and that the "physician and nurse almost had no transfer of information" while the patient was in the ED. S/he stated that with a typical case s/he would have time to treat the patient, determine whether the patient was able to remain stable, get discharge paperwork together and review the discharge instructions with the patient. S/he stated with this case s/he "did not have the time to do this and that there were things going on that s/he was not aware of"'. S/he also stated that s/he had received a phone call from the charge nurse at the receiving facility who informed him/her that Patient #1 was in their ED. S/he stated that s/he gave the charge nurse a report regarding the patient and stated s/he would notify the ED physician who evaluated the patient to call and give a report.

Per interview on 1/7/20 at 8:06 AM with the treating ED Physician, s/he stated that his/her usual practice with a patient who comes into the ED intoxicated with suicidal ideation was that the patient would be put on one to one monitoring with a staff member, would be closely observed, and would typically stay in the ED approximately six to eight hours. S/he stated that s/he would perform an initial assessment of the patient and then when the patient sobered up s/he would re-examine the patient and counseling services would be contacted so they could evaluate the patient and recommend that the patient be discharged home with a safety plan and/or be admitted to inpatient psychiatric facility. Regarding the case with Patient #1, s/he stated that s/he was busy with another patient and heard the call from EMS on the ED scanner. S/he stated that when s/he first went into the room the patient was angry, loud, aggressive and "obviously intoxicated". S/he stated that the patient did not exhibit any "respiratory issue" and "protected" his/her "airway". S/he stated that "in my mind" s/he "could go to a place to sober up". S/he stated that s/he "knows counseling will not evaluate a patient if the patient was intoxicated". S/he stated that the patient was very "agitated", and s/he was "looking at chemical and physical restraints and did not want to do this". S/he stated that s/he "had in mind police could keep the patient safe and that there was a facility to keep patients until they sobered up". S/he confirmed that s/he "would consider suicidal ideation a medical emergency"; and that "we should have kept the patient until sober". S/he stated that the receiving hospital had called and reported to him/her that Patient #1 was in their ED. S/he stated that s/he spoke to the ED provider at the receiving hospital and discussed the case with him/her. S/he stated that s/he "never intended" for Patient #1 to "end up" in another hospital; and that s/he "did not feel the patient was competent to go home".

Upon further record review of an ED physician's progress note from 11/5/19 at 2:30 AM from the receiving facility, the patient was brought to the ED by police for reports of suicidal ideation and intoxication. The patient reported that the police were called by his/her family secondary to suicidal threats. The patient admitted to drinking alcohol and using Tramadol and Oxycodone this evening. S/he was apparently agitated and uncooperative for police; however, upon arrival to the ED had been cooperative. The patient had already been seen by another hospital earlier. The patient admitted to chronic suicidality but did not mention any specific intent or plan. The patient complained of anxiety. S/he was awake and alert with a rapid heart rate and pressured speech. The patient did not exhibit delusional thoughts. The plan was to obtain a urine toxicity screen, a breathalyzer, observe until sober, and have a crisis evaluation.

Per review of the policy "EMTALA Guidelines"-approved 11/2019 it read, "Transfer: the movement (including the discharge) of an individual to a facility outside the Hospital at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the Hospital, but does not include such a movement of an individual who (i) has been declared dead, or (ii) leaves the facility without the permission of any such person ... ....The Hospital may not transfer individuals who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the individual. A transfer of a potentially unstable individual to another facility may only be for reason of medical necessity."