HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure an accurate central log at the behavioral health business office contained an entry for each individual who presented there seeking assistance with times of patient's arrival and departure. The central log was at odds with other hospital documentation. This had the potential to mask long patient wait times, skew the number of patients who might have left against medical advice or without being seen, and obfuscate the true status of patient dispositions, among other detrimental consequences.

Findings were:

Facility policy #BH 020 entitled "EMTALA Log," last revised January 2019, included the following:
"SCOPE:
The Behavioral Health System Access Department and Business Office
PURPOSE:
To abide by the Emergency Medical Treatment and Active Labor Act worked [sic]

POLICY: Each person that physically presents to Northwest Texas Healthcare System and the Behavioral Health Unit for an assessment and/or admission shall be logged in the EMTALA ... Log.

PROCEDURE: ...
2. The Intake Specialist will review the Patient Registration form and complete the following sections of the EMTALA Log:
a. Date
i. Patient Name
ii. Age
iii. Sex
iv. Arrival Time
v. Arrival Mode
vi. Presenting complaint
vii. Assessment Time (time assessment begins) ..."

In an interview with Staff #1, Director of Nursing Behavioral Health, on 8/5/21 at 10:51 a.m., she was asked how the Pavilion assessment process operated. She stated, "If someone comes in off the street, it depends if the business office is open. If it is, they'll enter there. If not, they come straight to us [in Access] and they sign in..." The Access area was located down a hallway from the business office. It consisted of a large central room that served as a patient waiting or holding area, with numerous smaller locked rooms around its periphery. These included triage rooms, a smaller and more private waiting area, a staff office, and an entrance to the rest of the Pavilion. It also had an external door where emergency vehicles and law enforcement could bring psychiatric patients to the facility, and where walk-in patients entered if the business office was closed. Staff #1 continued, "If the business office is open, they sign in [at the business office] and the business office lets Access [staff] know. They come to get us. Access does vital signs, assesses, calls the doctor and tells them what the findings were. The doctor says to admit or not..."

When asked how patients sign in to be seen, she stated, "Once they come in, they sign in. We have two EMTALA logs, one for Business Office and one for Access." When asked what the difference was between the two, she stated, "Because - from my understanding - we have to capture anyone who comes in off the street. Let's say they come in, something happens, they make it to the ED for some reason, we need to account for them." She went on to say, "If the business office is open, they sign in there ... That's 8:00 a.m. to 5:00 p.m. Monday through Friday. If it's not within those hours, they come in through Access. But everybody goes on the Access log. Even if they go to the business office, they will get signed in on the Access log." When asked if a patient who entered through the business office would wait in the business office waiting room until they were assessed by Access, she stated, "Yes." When asked if the time waited was recorded even when the business office was closed, she stated, "Yes.


A review of behavioral health Business Office & Access area EMTALA logs revealed issues regarding inconsistent documentation of accurate patient arrival/departure times, as well as dispositions. Items included the following:

* On 7/1/21, Patient #10 presented to the Business Office at 12:00 pm there was no "departure time" but "disposition" stated "Access" - he did not appear on the Access log. When Staff #1 tried to open the "chart" for 7/1/21, it wouldn't open. There was no information. He again presented to the Business Office on 7/2/21 at 8:10 am with departure time 8:40 am. His disposition was documented as "Access" ... A log indicated he was seen at 8:40 with a 10:15 referral.

* On 7/3/21, Patient #16 presented to the Business Office at 2:09 pm. There was no departure time, but "disposition" stated "Access." He did not appear on the Access log for 7/3/21, but was listed on the Access Log on 7/5/21.

* Patient #11 presented to the Business Office at 12:05 pm on 7/23/21. Her departure time to "Access" stated "12:30" which was crossed out. Written above that was "left." The Access log on 7/23/21 stated she arrived at 12:40 pm with departure time 1300, and disposition "pt left w/o eval." When asked about this, Staff #1 could not open the record. Consents were able to be reviewed, but there was no note or assessment. Staff #1 stated, "Ideally, they would make a note."

* On 7/23/21, Patient #13 presented to the Business Office at an unknown time. Her departure time to Access was noted as "1230." The Access log on 7/23 noted "arrival time 1230 with departure time 1630 and disposition admit" which was crossed out and "referred" written above.

In an interview with Staff #7, LMSW, regarding Patient #13 on the morning of 8/11/21, she stated, "She [Patient #13] had made some statements where we wanted to refer her to be inpatient, so we walked her upstairs to get assessed by Access." When asked why her note indicated "Admitted to inpatient treatment," Staff #7 stated, "I was under that impression because I spoke with the nurse practitioner." She went on to say, "I brought her [patient] to Access and stayed with her until she got assessed. I probably wrote this note because I was under that impression and the nurse practitioner was as well [that the patient was going inpatient status]." Staff #1, sitting in on the interview, stated, "We should have gone back in and put another note." When asked why she wasn't admitted, the case manager stated, "I would have to talk with [Staff #6, psychiatrist]. She came back to us on Monday and she was doing better on Monday. I think it was due to lack of sleep and some of those other things going on. She was a little brighter, talked with our nurse practitioner... I know that [Staff #6] saw this patient." The following timeline incongruities were noted by surveyors:
-- 1339 - [Staff #6] released
-- 1519 - [Staff #6] documented pt meets inpt criteria (documented as 1640)
-- 1550 - Patient signed referral/refusal of treatment

* On 7/29/21, Patient #7 presented to the Business Office at an unknown time. Her departure time to Access was noted as 16:35. The Access log arrival time was 1625 with departure at 22:10. Patient #7's disposition was "Admit," which was crossed out and AMA with written below this.

* Patient #14 presented to the Business Office on 12:44 on 7/31/21 and was noted to have an emergency medical/psych condition. His departure time from the business office was "1445" with no disposition documented. The Access log arrival time was 1445 with departure time 2215 - 8 hours later - with disposition "admit."

* Patient #5 presented to the Business Office at an unknown time on 8/9/21. Her departure time to Access was noted as 1530. The Access log arrival time was listed as 1540 with "departure time 2252." This had been crossed out and "2317 error" had been written. Her disposition of "admit" had been crossed out and "Left AMA; AMA" was written in on the log.

* Patient #15 presented to the Business Office at 10:00 am on 8/9/21; departure time to Access was left blank. Patient #15 did NOT appear on the Access log for 8/9/21.

Based on a review of facility documentation and staff interviews, the facility failed to ensure each individual presenting at the main hospital emergency department or the psychiatric emergency departments, comprised of the Access area and Business Office, received an appropriate medical screening examination which was provided without undue delay thus allowing for initiation of stabilizing treatment for 1 of 20 patient records reviewed [Patient #2]. In addition, the hospital did not triage patients waiting in the behavioral health business office, and were not providing routine monitoring. These were patients presenting for a variety of mental health conditions, including patients potentially suicidal.

Findings were:

Facility policy #RRI 012 entitled "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 1/2021, included the following:
"SCOPE:
This policy applies to the following staff at Northwest Texas healthcare System: Administration, Registration, Employed Physicians, Dedicated Emergency Departments, including Freestanding Emergency Departments, Transfer Centers, On-Call Physicians, Hospital-based entities, Hospital Departments on and off campus, Urgent Care Centers/Clinics ...

POLICY:
Hospital will provide an individual with an appropriate Medical Screening Examination with the Capability of Hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an Emergency Medical Condition exists, regardless of the individual's ability to pay, when: (a) there has been a request for medical care by an individual within a Dedicated Emergency Department; (b) an individual requests emergency medical care on Hospital Property, other than in a Dedicated Emergency Department; or (c) a Prudent Layperson Observer would recognize that an individual in a Dedicated Emergency Department or on Hospital Property requires emergency treatment or examination, though no request for further treatment is made. If an Emergency Medical Condition is determined to exist, Hospital must provide either: (a) further medical examination and any necessary Stabilizing Treatment with the Capabilities of the staff and facilities available at Hospital ...

DEFINITIONS: ...
F. Emergency Medical Condition ("EMC") means:
3. With respect to an individual with psychiatric symptoms:
a. that acute psychiatric or acute substance abuse symptoms are manifested; or
b. that individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be a danger to self or others ...

N. Medical Screening Examination ("MSE") is the process (which begins with the initial collection of an individual's vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening ...

X. Stabilizing Treatment means, with respect to an EMC to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility ... or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/herself or others ...

AA. Triage is a sorting process to determine the order in which individuals will be providing an MSE by a physician or QMP based on presenting signs and symptoms. Triage is not the equivalent of an MSE and does not determine the presence or absence of an EMC ...

PROCEDURE:

A. When a Medical Screening Examination is Required
An individual MUST receive an MSE, within the capabilities of Hospital's DED, including ancillary services routinely available, to determine whether or not an EMC exists ... if:
1. The individual comes to Hospital's DED, including by transfer from another hospital, and a request is made on his or her behalf for examination or treatment for a medical condition.
2. The individual arrives on the Hospital Property other than a DED and a request is made on the individual's behalf for examination or treatment for an EMC...

C. Extent of Medical Screening Examination ...
4. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric/behavioral health screening. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others ...

D. No Delay in Medical Screening Examination. Once EMTALA is triggered, Hospital must not delay in providing an MSE or, if an Emergency Medical Condition is determined to exist, necessary Stabilizing Treatment ..."


A review of the emergency department record of Patient #2 revealed he was brought to the behavioral health Access emergency department (ED) in the late evening of 6/20/21. An assessment by Staff #3, LMSW, at 11:30 p.m. on that date, and modified on 6/21/21 at 1:03 a.m., included the following:

"Comment on Presenting Problem
This is a 28Y M who presents to Access INVOL on APD/EDO (Amarillo Police Department/emergency detention order) for acute psychosis and homicidal threats. No previous admissions to this facility. Pt's medical, psychiatric, and social history is largely unknown except for what was reported by sister and APD officers ...

Pt arrived at Access transported by AMS and accompanied by APD. APD stated that AMS checked him out and "he is fine, no drugs no medical issues that require transport to the ER." Pt was handcuffed and strapped to a gurney. Pt was observed to be dressed in only shorts, no shirt or shoes, with black marker on his stomach. APD took the handcuffs and restraints off of the pt, who then went to sit on a couch. Pt answered a direct question about food/water. Pt became aggressive and APD/Security placed pt in a hold against the wall. This writer expressed concern for the pt's medical needs, specifically that he would need to go to the ER for medical clearance due to acute psychosis and aggressive behaviors, as well as safety concerns for other patients and staff. APD said that they did not want to take the pt to the ER because AMS had already checked him out, and they were worried that he would hit someone. Pt became more aggressive and was transitioned to a hold on the ground by APD/Security, where he could not be de-escalated by APD or Security and continued to become more combative.

House Supervisor was called to respond to the pt's escalating violent behaviors. Psychiatrist on-call was consulted, who recommended that the pt be brought to jail where they could order a psych consult while in placement. Pt was transported to ER for medical clearance to go to jail at the discretion of APD after he was d/c (discharged) from Access and referred to jail; pt was not referred to ER by Access ..."

Patient #2 was medically cleared at the main hospital emergency department on 6/21/21 at 12:14 a.m.

Physician notes from the ED encounter included the following:
"48-year-old [sic] male with a history of traumatic brain injury who seems to be also homeless but not staying with family who became very violent today and tried to kill 13-year-old family member and then also became very aggressive with the family so police was involved in the patient got into an altercation with the police [sic]. Patient only has an abrasion other than the left upper shoulder and the knees but no significant other traumatic injuries. Patient very agitated and required multiple people to subdue. Patient required Haldol and Ativan upon arrival to emergency department due to continued aggressive behavior. Apparently the patient was initially taken to the Pavilion by the police but they refused the patient due to his state. Patient will end up needing to be medically cleared for incarceration. While in the emergency department he also got medicated with Benadryl IM besides the Haldol and the Ativan initially. Patient seem [sic] to have responded well to that and became more docile. Apparently the patient has been hearing voices and probably has some complement of psychosis. Nevertheless at this point there is no acute medical issue that would require further evaluation emergency department patient setting so the patient will be released to police custody ..."

Results of a physical examination at the ED included the following:
"General: Alert, diaphoretic ...
Neurological: rambling ...
Skin: Warm, pink, intact, moist, no pallor, no rash ...
Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion, No edema ...
Musculoskeletal: No swelling, long toe nails, abrasions over both knees and an abrasion over L shoulder ..."

ED vital signs obtained at 12:12 a.m. on 6/21/21 were as follows:
* pulse 128
* respiratory rate 18 breaths/minute
* temperature 99 deg F
* blood pressure 129/89
* oxygenation 98% room air


ED nursing narrative notes on 6/21/21 included the following:

- 12:12 a.m. - "Pt sitting up in bed, remains having auditory hallucinations and loose ideations. APD and security remain at bedside, he remains in custody in restraints"
- 12:23 a.m. - "Pt given medication IM per MAR (medication administration record)"
- 12:39 a.m. - "APD remain with pt. He is more calm and helmet is removed"
- 1:30 a.m.: -- "Pt remains in APD custody. He is ambulatory to wheelchair and is alert with psych behavior crisis. Vitals remain stable and he is wheeled out with APD."

Patient #2 was discharged at 1:33 a.m. from the main emergency department at Northwest Texas Hospital. He could not be returned to the behavioral health unit for treatment as he had already been denied admission.

In a telephone interview with a representative of the Amarillo Police Department on 8/11/21 at 2:54 pm, he stated, "...My team and I primarily do mental health calls. We go to the Pavilion [aka Northwest Texas Behavioral Health] and do EDO (emergency detention order) patients all the time. We see the frequency of these infractions more than the general public and other folks realize. I've been doing this for 15 years and it's gotten progressively worse and worse [at the Pavilion]. They have new administration [in the Pavilion] fairly often... Ultimately, there's a handoff that has to happen. I had five meetings with the Pavilion before I made the complaint to you guys. To me, it's been an excuse to skirt the line and not deal with the patients that they don't want to deal with."

When asked what happened last night, he stated, "We took somebody out there for Emergency Detention. I've been working with the Health and Safety Code long enough to know -- we have to take them to the closest mental health facility, which is the Pavilion 99% of the time. Once we make that presentation, and hand them over and say, 'Here please assess them,' our authority basically ends there. The public doesn't understand, we just have to present them. The Pavilion will refuse to open the door. They tell us through the window they're closed. On the complaint I filed [referring to issue with Patient #2], they admitted him and then they say, 'Nah, he's not admitted anymore.' We take a person in. They [Pavilion staff] tell the officers they're accepted and then our officers will leave. They seem to have no secure procedure to have patients get medical clearance over at the main hospital ED, and the patient will just leave. When they assess this person, they [patients] just leave. John Doe comes in, they say 'Yes, accept,' police leave. Last night they told the patient to walk across the street to the ER [to get medically cleared], but the patient will just leave because he doesn't want to wait there." The APD officer went on to say, "They're almost 2 different entities [referring to the main hospital ER and the Pavilion ER]. I feel for the ER. Basically, the Pavilion will pawn off their patients to the ED. We'll send them over there. There's no contingency there for the ER to take care of them. They'll just walk out. Then it becomes our responsibility again. John Doe left ... that was your patient, you're responsible for that patient ... Like I told CMS folks in Dallas, I'm not trying to be a thorn in anyone's side. I want to do what's right. Basically, they're [the hospital] forcing, under our badge, things that they need to do. I think something bad's going to happen and we're going to be liable for it." When asked about the Access area at the Pavilion, he stated, "I've thought [what if] there's a fight in there -- someone breaks all the glass. Your staff's not even protected."

When asked if there were specific staff members who often turned patients away when they presented to Access, he stated, "More often than not, it would be the night crew. They say, 'We're full, we're closed' and don't even open the door. Like I told the CEO over there ... 'I get it, there are different shifts. Things happen at night. There's not enough staff. You can't just close your emergency psych facility.' She says they're going to do something, but nothing changes."

When asked if he had any documentation regarding the meetings, he'd had with hospital administration, he stated, "They've all been over Zoom video conference. So, the last meeting - [physician name], their medical director -- when I initially requested to speak about this incident, I tried to talk to them and meet them in the middle because sometimes we bring someone in and they're violent because of psychosis or whatever. We do not just want to open the door and push them in there and say, 'Here you go, have fun.' You've got to meet us in the middle and come up with some protocol to handle a patient like that. First, have staff trained. Second, have a secure room where you can figure out what you're going to do. They go off on this thing, 'We can't do anything with a handcuffed patient.' I say, 'Guys, we don't work here. I bring them in with handcuffs for their safety, your safety, my safety.' That's what really happened with [Patient #2]. Someone came down with [Staff #3]. They were arguing among themselves -- should they give or not give meds so they can get them out of handcuffs? When I talked about that with the medical director, he tried to make the point that the person was just high. OK, well, 'How do you know that [medical director]? I didn't have the labs.' According to the call, he [Patient #2] had not left the apartment in 2 years. He was living with family. He never gets out, never had drugs. How would he get those? There was no suspicion he was on any type of substance. [The medical director] then says he means they're too violent. Then I asked what that means -- what does 'too violent' mean? You can't just have a blanket policy like that when you're a psychiatric facility."

When asked how many officers were involved in [Patient #2's] incident, he stated, "Two of my CIT (crisis intervention team) officers went out and actually took him into custody. Officers had previously been called earlier that day. They didn't have to take him at that time, but they notified the other officers so they could be aware. Well, Murphy's law, something happened, the sister called. I watched the body cam footage. As soon as they went in, you could tell this guy was psychotic. The officers say, 'You have to come with us.' He says, 'OK' and pulls 2 tufts of hair out of his head and goes outside and starts eating grass. When officers see something, by penal law, they look and say, 'Is this person sick? Jail's not the best place for this person. Yes, he put hands on a kid, but it's because of the psychosis.' Ultimately, they had to arrest him for that charge because there was nowhere else to take him because the Pavilion would not take him. He didn't need to go to jail ... There was only one car with two CIT officers who took [Patient #2] to the Pavilion."

When asked if Patient #2 had been restrained for 40 minutes, the police representative stated, "Yes, I think I counted 22 minutes while staff was going and coming deciding what to do. They [officers] didn't want to take the handcuffs off, and when they did, of course he goes after [Staff #3], and they had to hold him again for 10 minutes more." When asked if [Patient #2] looked blue in the lips or face or was sweating, he stated, "No. We have general knowledge about medical clearance. We use judgement and see if they do need medical treatment. We've been abused by the Pavilion for years, saying they need medical clearance. If they've [patients have] ODed or are bleeding, if there's an immediate need to go medically, or it's clear they need medical treatment, they go to the ED. They address that. Officers did not say anything to me or indicate that."

When asked if CIT officers were trained in emergency medical treatment and mental health, he stated, "They are - absolutely. One of the officers on the call was a certified mental health peace officer. Myself and all of my full-time CIT officers are. We're all trained."


In an interview with Staff #2, CEO Behavioral Health, and Staff #1, Director of Behavioral Health Nursing, on the morning of 8/10/21, referring to the TAC (Texas Administrative Code), Staff #1 stated, "I know it says we cannot take any patients in forensic cuffs. According to them [APD], they're supposed to bring them to the closest behavioral health facility. Some of our regulations and their regulations don't jibe. As long as they pose a safety risk, the police will remain in control. Once they can release them, then we'll take over from there. They always stay to find out the end result." When asked if Patient #2 arrived with five police officers, she stated, "I wasn't here, so I can't 100% say that but I know there were two vehicles."

When asked about the process of admitting a patient at night, Staff #1 stated, "When we admit in the middle of night, the doctors don't do the admit orders. The nurse calls the doctor. The nurse says we have a patient with these complaints and presenting problems. They'll [the doctors] say 'admit.' We get the verbal order over the phone." When asked if they give medications during the night to a newly admitted patient, she stated, "Yes. It depends if they're on any medications. It depends if they've overdosed somehow. It depends if they [doctors] want them to dry out. We get orders sometimes -- especially if they're diabetic -- or if they're aggressive or agitated. We're going to call and get something like that as well ... We do have some prns like Vistaril, trazodone for sleep, milk of magnesia, no Ativan or anything like that, Zyprexa zydis sometimes."


In a telephone interview on 8/10/21 at 3:37 p.m. with Staff #3, Access LMSW who was working the evening of 6/20/21, she was asked about the incident with Patient #2. She stated, "If I'm remembering right, it was an individual that was brought in on papers because he had been having some bizarre homicidal behaviors and he had threatened to kill his nephew..." Then she discussed interactions with the Amarillo Police Department (APD), stating, "Yes, some of the officers actually have keys to our facility. They are allowed to come into the door without having a staff member being there to let them in. Normally, we meet them at the door. The patient [Patient #2] did come in in handcuffs. It's my understanding we cannot have a patient in handcuffs in the building because it's a mechanical restraint. He was pretty escalated. We were trying to de-escalate and talk with [Staff #6, psychiatrist]. We were trying to see if we could get him back to the unit...

Because of his escalating behaviors, we were unable to get him cleared. We were calling nurses to come help us because there were only two of us in Access. I remember what was said. There was a lot of push back. He was aggressive. We have a zero-tolerance policy on that - on violence. We wanted him to go to ER to get medically cleared. He never came back. I heard he was taken to jail afterwards ... He couldn't stay here because of the behaviors -- because we can't handle that. He made a homicidal threat or gesture toward his nephew. I said, 'I can't tell you to take him to jail, but in his current state we cannot adequately treat him.' We needed him to get medically cleared first. I think it was someone from the ER who told me he was taken to jail ..."

When asked to clarify what she'd said about zero tolerance, Staff #3 stated, "For violence. It's posted in our facility on the door outside, there's a zero tolerance for workplace violence. He was being very, very violent, which would pose a risk to our patients and staff." When surveyors mentioned that behavioral health patients often display aggressive acting-out behaviors and asked how it was possible these behaviors weren't tolerated, she stated, "I mean anybody who becomes a risk to themselves or someone else -- we have de-escalation or handle with care training. This patient was definitely an imminent danger to himself or others..."

When asked about the night when APD brought in Patient #2, she stated, "There were only two of us in Access -- I believe that is right. [Another Access employee] and I are usually the ones that work on a Sunday night. I was working as a call spec. On Sundays, I'm usually call spec." When asked if she also sometimes performed the assessments those nights, she stated, "Yes, I try to help her out ..." When asked if the amount of work ever endangered staff or patients, she stated, "I think there are practices that could be looked at to be improved. Perfect example -- I think if APD did not have access to our building with a key, it would be better. With that patient, we would have gone out and seen they were not able to remove the handcuffs. We would have told them out there that we couldn't take the patient. Instead, they came in, had to remove the handcuffs and he had to be pinned to the floor. That's not fair to the patient. We would be able to talk to them before the handcuffs were off ... The patient is not supposed to be restrained for a certain amount of time. We have limited resources here. It's basically a lobby. If he had gone to the ER, maybe he could have been seen by a medical professional."

When asked if she had any concerns about the Access area, she stated, "It's a very difficult place to be in. It's basically just a lobby. We can't medicate patients there if they need it, and things like that. I think that patient might have benefited from medication. Typically, if a patient becomes agitated, they might get emergency meds, but we cannot do that in Access because we are not allowed to. That's what my bosses say -- unless a patient has been medically cleared, because a patient has to be seen by a doctor."

When asked how many police officers restrained Patient #2, she stated, "It was multiple - 2 or 3 police officers and 2 or 3 security guards that came over. All of them [were restraining]. None of the pavilion staff or access staff were involved in the restraint." When asked to clarify her statement about emergency medications in Access, she stated, "We are not supposed to give any medications unless they were medically cleared..."


In an interview with Staff #1, Director of Behavioral Health Nursing, on 8/10/21 at 4:28 p.m., when asked for her definition of a medical screening exam, she stated, "One way can be by telemed with freestanding ED physicians. They ask them questions - whether they're medically stable. If the person's not medically stable or they're detoxing, we'll send them to our [main hospital] ED." When asked if it is hospital policy that emergency psychiatric medications are not given until someone is medically cleared, Staff #1 stated, "It's best practice, not in our policy." When asked if it would ever happen, she stated, "That someone would get meds without being medically cleared? It's a possibility ..." When asked if the patient might have been administered emergency psychiatric medication had he not been in handcuffs, Staff #1 stated, "Had I been here, I might have. [Staff #4] told me over and over again that he [the patient] looked like he was about to die. Being a nurse, I would not have given a med to somebody who was about to die ... We are the same facility [referring to the main hospital]. They treated him in the ED. They sent him to the ED because he was gray and sweating profusely." When asked if they would send a patient away because they were in handcuffs, Staff #1 stated, "We would not refuse to see them. We would wait until they removed the handcuffs." When asked why a patient couldn't be assessed unless out of handcuffs, she stated, "In 2014, our corporate people gave direction. You cannot do any nursing care if they are in handcuffs."

When asked about the zero-tolerance violence policy, Staff #1 stated, "We are a zero-tolerance campus, it's posted at every door. This is what's hard to explain to people who don't work in psych. Our main [hospital] CEO, our main security -- that's their goal. We can't [have a zero-tolerance policy]. We wouldn't have many patients. However, it's still posted on our doors. But it's not like we call every time a patient calls us a bitch. It's a different world over here ..."

When specific comments made by Staff #3 regarding being able to tell police outside the Access area to take the patient elsewhere were brought up by surveyors, Staff #1 stated, " ...That's wrong."

Staff #2, CEO Behavioral Health, came into the room and joined the interview. She paraphrased Staff #3's remarks, "'Police -- if they don't have a key to Access, we can go out and interact and see that they can't take handcuffs off. Then we can't see them?'" Then she added, "Oh no. That's wrong."

When asked if there's a policy that addresses not giving emergency medications in access, Staff #1 stated, "That's what I was told." When discussing the police custody and handcuff issue, Staff #2 stated, "I think they can be assessed. I think the issue is, if they don't release the handcuffs, what can we do with them? If police refuse to remove handcuffs or hold them in a different manner, even if not in handcuffs, as soon as the handcuffs come off, they're ours. Each situation, each scenario we're presented with, is different ... We have a staff member serving various roles in Access that believes the zero-tolerance policy applies to psych. Well, we wouldn't have anyone in our hospital ..."

In an interview with Staff #1, Director of Behavioral Health Nursing, on the morning of 8/12/21 at approximately 10:00 a.m., she said the behavioral health unit had not had any recent incident reports related to patients in the Business Office. She added, "The last incident we had in there was quite a while back - 2 years ago or so." When asked if it would be noticed/noted by business office staff if a potentially suicidal patient went into the restroom for a prolonged period, she said, "I don't know that they would notice if someone was in the restroom for a long time. They'd call Access if something was acutely wrong." When asked if triage was performed in the Business Office, as the only staff member manning the office was a "financial counselor," Staff #1 said no triage was performed in the business office area. When asked if there was a triage policy for Access, she replied "No." She added, "It would be first come first served for sending people back to Access. However, if someone is more agitated or aggressive, maybe pacing, we'd try to see them first." Surveyors brought up that a depressed patient would have a more subdued presentation, but might be more acute. Staff #1 confirmed, "We wouldn't know unless we talked to them. But something could happen at a doctor's office or at a clinic. That could happen anywhere ..." She confirmed that business office financial counselors were not licensed or trained. Staff #1 also added that there were no staffing sheets for the Business Office admissions area.

The job description for a financial counselor position was reviewed. It included a position summary as follows: " ...responsibility and accountability of admission/registration processes ... and initial financial arrangements for accounts ..."