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Based on document review and staff interview, the Acute Care Hospital's (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided within its capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed (Patient #1). Failure to provide patients with an appropriate MSE places all patients at risk for an undetected emergency medical condition. The ACH's administrative staff identified an average of 1,941 patients per month who presented to the dedicated emergency department seeking medical care.

Findings include:

1. Review of the policy "Emergency Medical Treatment and Labor Act (EMTALA)/Transfer of Patients to Other Health Care Facilities," Last reviewed 4/21, revealed in part:

a. " ...The MSE determines the presence or absence of an EMC and is provided within the capabilities and capacity of the hospital, including the availability of on-call providers. The scope of the examination is tailored to the individual's presenting complaint and medical history. The MSE may include various diagnostic tests and use of other ancillary services. Triage is not equivalent to the MSE."

The hospital's policy is not consistent with the EMTALA requirements in that irrespective of the hospital's capacity, it must provide an appropriate MSE within the capabilities of the hospital's emergency department, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists.

2. Review of Patient #1's medical record revealed:

a. On 5/10/23 at 4:29 PM, Patient #1 presented to the ED by law enforcement with a court order for inpatient behavioral health (BH) care.

b. On 5/10/23 at 4:29 PM, RN L triaged Patient #1 and noted the patient refused to answer any of the suicidal or homicidal questions, and no suicide scale score was completed. Patient #1's personal items were removed, they were wanded (using a metal detector wand) by public safety, public safety remained at bedside, the room was assessed, and necessary items were removed for Patient #1's safety.

c. On 5/10/23 at 4:35 PM, patient was evaluated by DO A, and was noted that when the police arrived to serve the court order to Patient #1, they became extremely violent and required 5 officers to hold them down, subdue them, and place them in handcuffs. DO A also noted Patient #1 presented with scattered thought processes and racing thoughts from being the president to the dictator, and was obviously agitated and very diaphoretic.

d. On 5/10/23 at 4:36 PM, DO A ordered Patient #1 to receive one dose of haloperidol (antipsychotic medication used to treat mental disorders) 5 milligram (mg) intramuscular (IM) (injection into the muscle) and one dose of lorazepam (sedative used to relieve anxiety) 2 mg IM.

e. On 5/10/23 at 5:04 PM, Patient #1 was placed in BH room 1 (BH-1), in the crisis hall (secured hall), closest room to the nurse ' s station.

f. On 5/10/23 at 5:16 PM, initial elopement risk screening was completed by RN L, and the following interventions were initiated: 15-minute checks, placed in green scrubs, a wander guard (elopement band) was applied, their shoes and jacket were placed out of sight, they were restricted to the unit, and an elopement risk was added to their plan of care.

g. On 5/10/23 at 5:17 PM, RN L administered one dose of haloperidol 5 mg IM and one dose of lorazepam 2 mg IM.

h. On 5/10/23 at 5:25 PM, DO A re-evaluated Patient #1 and noted they were no longer combative and were very cooperative. DO A failed to order a psychiatric evaluation or order scheduled medications to treat Patient #1's mental health condition.

i. Patient #1 was moved from the crisis hall, out to the main ED, placed in a trauma room located directly across from the nurse ' s station, and placed on 1:1 observation. During the survey team ' s investigation, the ACH staff were unable to provide a date or time that Patient #1 was moved from the crisis hall, if an assessment was completed on Patient #1 prior to them being moved, or who made the decision to move Patient #1.

j. On 5/11/23 at 9:00 AM, a suicide screen, mental health assessment, and behavioral health screening was completed on Patient #1, and it was noted that interventions continued. Patient #1 had no behaviors or concerns noted throughout the day on 5/11/23.

k. On 5/12/23 at 6:00 AM, a suicide screen, mental health assessment, and behavioral health screen was completed on Patient #1, and it was again noted that interventions continued.

l. On 5/12/23 at 12:03 PM, nearly 2 days after presenting to the ED, PA D, performed a psychiatric history and physical by telehealth (remote healthcare by video). Patient #1 was diagnosed with acute schizophrenia (chronic mental health condition), and needed inpatient mental health hospitalization. PA D noted that Patient #1 lacked insight into their illness, and was disorganized. Patient #1 was not taking their medications, and told PA D they could not take mediation, because every medication causes harm. The plan was to admit Patient #1 to the inpatient BH unit when a bed became available. PA D failed to order treatment for Patient #1 prior to their elopement.

m. On 5/12/23 at 1:45 PM, RN P documented that Patient #1 verbalized they felt like running. While RN P was on the phone with staff from the crisis hall, working on getting Patient #1 moved back to the crisis hall, Patient # 1 ran through the main ED doors. RN P noted that the wander guard elopement alarm did not go off, even though Patient #1 was wearing a wander guard.

n. On 5/13/23 at 6:37 AM, Crisis Team Worker G documented after a review of the video footage of Patient #1's elopement, Patient #1 eloped from the ED at 1:43 PM, was off the property at 1:44 PM, at 1:48 PM the law enforcement was notified, and at 3:37 PM Patient #1 was brought back to the ED by law enforcement, and taken to the crisis hall.

o. On 5/12/23 at 3:53 PM, MD B documented Patient # 1 was located and returned to the ED by the law enforcement. MD B discussed Patient #1's case with PA D, and planned to admit Patient #1 to the ACH's inpatient BH unit. MD B ordered Patient #1 to receive 1 dose of ziprasidone 10 mg IM.

p. On 5/12/23 at 4:09 PM, MD B ordered Patient #1 to receive risperidone (antipsychotic medication used to treat mental disorders) 1 mg scheduled twice daily.

q. On 5/12/23 at 4:10 PM, MD B ordered Patient #1 to receive valproic acid (anticonvulsant medication used to treat mood and anxiety disorders) 250 mg, two tablets scheduled daily at bedtime.

r. On 5/12/23 at 5:17 PM, RN O gave ziprasidone 10 mg IM to Patient #1.

s. On 5/12/23 at 5:57 PM, MD B documented there were no beds available in the ACH's inpatient BH unit, and the inpatient psychiatric provider suggested starting Patient #1 on risperidone twice daily and valproic acid at bedtime.

t. On 5/13/23 at 12:09 PM, approximately 3 days after presenting to the ED Patient #1 received their first dose of risperidone 1 mg and at 10:33 PM, their first dose of valproic acid 250 mg, two tablets.

u. On 5/15/23 at 2:14 PM, Patient #1 was admitted to the ACH's inpatient BH unit for psychiatric care.

3. During an interview on 6/29/23 at 10:00 AM, PA D recalled seeing Patient #1 in the ED for their initial psychiatric consult on 5/12/23. Patient #1 was brought to the ED by court order, was very delusional, having disorganized thoughts, and had been in the ED for 2 days before their elopement. PA D recalled Patient #1 making a statement that "I am a radio head and you're going to watch me leave." PA D reported the ACH has changed their process of treating BH patients due to Patient #1's elopement, and now they will be consulting within 24-hours. PA D reported that the ACH's psychiatrist are not on call at night, but they utilized Integrated Telehealth Partners (ITP) (BH care by video) for after-hours or immediate needs. PA D identified that the crisis hall is not okay, because there is not enough room for patients. PA D reported that Patient #1 was allowed to elope, because he was kept in the main ER due to there not being room in the crisis hall for all the BH patients they had. PA D reported that following Patient #1's return to the ED, they were kept in the crisis hallway through the weekend due to their elopement risk, and the inpatient psychiatric provider admitting another violent patient prior to admitting Patient #1 to the inpatient BH unit. Finally, PA D reported that the ED providers usually order medications for patients in the ED, and that Patient #1 was very paranoid about medication and thought their medication was going to kill them, so it was difficult to get them to take medication.

Refer to tag A2406 for further details.

Based on document review and staff interviews, the Acute Care Hospital's (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed (Patient #1). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care places them at risk for an undetected emergency medical condition. The ACH's administrative staff identified an average of 1,941 patients per month who presented to the dedicated emergency department seeking medical care.

Findings include:

1. Review of Patient #1's medical record revealed:

a. On 5/10/23 at 4:29 PM, Patient #1 presented to the ED by law enforcement with a court order for inpatient behavioral health (BH) care.

b. On 5/10/23 at 4:29 PM, RN L triaged Patient #1 and noted the patient refused to answer any of the suicidal or homicidal questions, and no suicide scale score was completed. Patient #1's personal items were removed, they were wanded (using a metal detector wand) by public safety, public safety remained at bedside, the room was assessed, and necessary items were removed for Patient #1's safety.

c. On 5/10/23 at 4:35 PM, the patient was evaluated by DO A, who noted that when the police arrived to serve the court order to Patient #1, they became extremely violent and required 5 officers to hold them down, subdue them, and place them in handcuffs. DO A also noted Patient #1 presented with scattered thought processes, racing thoughts and delusions about being the president and a dictator, and was obviously agitated and very diaphoretic.

d. On 5/10/23 at 4:36 PM, DO A ordered Patient #1 to receive one dose of haloperidol (antipsychotic medication used to treat mental disorders) 5 milligram (mg) intramuscular (IM) (injection into the muscle) and one dose of lorazepam (sedative used to relieve anxiety) 2 mg IM.

e. On 5/10/23 at 5:04 PM, Patient #1 was placed in BH room 1 (BH-1), in the crisis hall (secured hall), closest room to the nurse ' s station.

f. On 5/10/23 at 5:16 PM, initial elopement risk screening was completed by RN L, and the following interventions were initiated: 15-minute checks, placed in green scrubs, a wander guard (elopement band) was applied, their shoes and jacket were placed out of sight, they were restricted to the unit, and an elopement risk was added to their plan of care.

g. On 5/10/23 at 5:17 PM, RN L administered one dose of haloperidol 5 mg IM and one dose of lorazepam 2 mg IM.

h. On 5/10/23 at 5:25 PM, DO A re-evaluated Patient #1 and noted they were no longer combative and were very cooperative. DO A failed to order a psychiatric evaluation or order scheduled medications to treat Patient #1's mental health condition.

i. Patient #1 was moved from the crisis hall, out to the main ED, placed in a trauma room located directly across from the nurse's station, and placed on 1:1 observation. During the survey team's investigation, the ACH staff were unable to provide a date or time that Patient #1 was moved from the crisis hall, or if an assessment was completed on Patient #1 prior to them being moved, or who made the decision to move Patient #1.

j. On 5/11/23 at 9:00 AM, a suicide screen, mental health assessment, and behavioral health screening was completed on Patient #1, and it was noted that interventions continued. Patient #1 had no behaviors or concerns noted throughout the day on 5/11/23.

k. On 5/12/23 at 6:00 AM, a suicide screen, mental health assessment, and behavioral health screen was completed on Patient #1, and it was again noted that interventions continued.

l. On 5/12/23 at 12:03 PM, approximately two days after presenting to the ED, Patient #1 was seen by PA D, and a psychiatric history and physical was completed by telehealth (remote healthcare by video). Patient #1 was diagnosed with acute schizophrenia (chronic mental health condition), and needed inpatient mental health hospitalization. PA D noted that Patient #1 lacked insight into their illness, and was disorganized. Patient #1 was not taking their medications, and told PA D they could not take mediation, because every medication causes harm. The plan was to admit Patient #1 to the inpatient BH unit when a bed became available. PA D failed to order treatment for Patient #1 prior to their elopement.

m. On 5/12/23 at 1:45 PM, RN P documented that Patient #1 verbalized they felt like running. While RN P was on the phone with staff from the crisis hall, working on getting Patient #1 moved back to the crisis hall, Patient # 1 ran through the main ED doors. RN P noted that the wander guard elopement alarm did not go off, even though Patient #1 was wearing a wander guard.

n. On 5/13/23 at 6:37 AM, Crisis Team Worker G documented after a review of the video footage of Patient #1's elopement, Patient #1 eloped from the ED at 1:43 PM, was off the property at 1:44 PM, at 1:48 PM the law enforcement was notified, and at 3:37 PM Patient #1 was brought back to the ED by law enforcement, and taken to the crisis hall.

o. On 5/12/23 at 3:53 PM, MD B documented Patient # 1 was located and returned to the ED by the law enforcement. MD B discussed Patient #1's case with PA D, and planned to admit Patient #1 to the ACH's inpatient BH unit. MD B ordered Patient #1 to receive 1 dose of ziprasidone 10 mg IM.

p. On 5/12/23 at 4:09 PM, MD B ordered Patient #1 to receive risperidone (antipsychotic medication used to treat mental disorders) 1 mg scheduled twice daily.

q. On 5/12/23 at 4:10 PM, MD B ordered Patient #1 to receive valproic acid (anticonvulsant medication used to treat mood and anxiety disorders) 250 mg, two tablets scheduled daily at bedtime.

r. On 5/12/23 at 5:17 PM, RN O gave ziprasidone 10 mg IM to Patient #1.

s. On 5/12/23 at 5:57 PM, MD B documented there were no beds available in the ACH's inpatient BH unit, and the inpatient psychiatric provider suggested starting Patient #1 on risperidone twice daily and valproic acid at bedtime.

t. On 5/13/23 at 12:09 PM, approximately three days after presenting to the ED, Patient #1 received their first dose of risperidone 1 mg, and at 10:33 PM, received their first dose of valproic acid 250 mg, two tablets.

u. On 5/15/23 at 2:14 PM, Patient #1 was admitted to the ACH's inpatient BH unit for psychiatric care.

2. The evidence in the medical record showed the hospital failed to provide an appropriate MSE to patient # 1, who presented to the ED with acute psychosis and delusions. The hospital's capabilities included an inpatient psychiatric unit with on-call psychiatrists, and elopement countermeasures such as alarms and door-locking mechanisms in the ED. The patient arrived at the ED on 5/10/23 and staff placed the patient in the crisis hall due to his heightened agitation. On 5/12/23 the patient had not yet been evaluated by psychiatry, and was moved from the crisis hall to a lesser restrictive area and eloped from the ED. Upon return by law enforcement, the patient received a psychiatric evaluation and on 5/13/23, a nearly three-day delay after arriving at the ED, the patient received maintenance medication (risperidone and valproic acid) while waiting for an inpatient bed to become available on the inpatient psychiatric unit.

3. During an interview on 6/29/23 at 9:30 AM, RN L recalled triaging Patient #1 when they were initially brought into the ED for admission. RN L recalled Patient #1 was triaged in the main ED, in room 17, with public safety and law enforcement present. Following triage Patient #1 was taken to the crisis hall, to room BH-1. RN L recalled patient #1 was changed into scrubs and was cooperative when taken to the crisis hall. RN L recalled working on 5/11/23 during the day shift, and Patient #1 was still in the crisis hall at that time.

4. During an interview on 7/5/23 at 12:00 PM, DO A recalled admitting Patient #1 to the ED. DO A reported Patient #1 presented to the ED with 5 police officers, swearing they were the president then the dictator, and it was difficult to get a history from them, because they were so psychotic. DO A recalled after they subdued Patient #1 with medication, they were resting in the crisis hall. DO A reported they could not recall how long Patient #1 was held in the crisis hall, but was there the remainder of DO A's shift (approximately 6 hours). DO A acknowledged he had significant concern with Patient #1 eloping, but they were calm after receiving haloperidol 5 mg IM and lorazepam 2 mg IM. DO A recalled Patient #1 was not able to give them a medication history. DO A acknowledged they did not communicate with Patient #1's outpatient psychiatric provider while caring for Patient #1. Finally, DO A reported that the ACH has changed how BH patients are seen in the ED, and that every psychiatric patient presenting with a 48-hour hold or court order will have a psychiatric consult order put in before the end of their shift.

5. During an interview on 6/29/23 at 8:30 AM, RN N recalled working the evening before Patient #1's elopement (5/11/23 into the morning of 5/12/23). RN N reported charting that Patient #1 was asleep, calm, and relaxed during their shift.

6. During an interview on 6/29/23 at 10:00 AM, PA D recalled seeing Patient #1 in the ED for their initial psychiatric consult on 5/12/23. Patient #1 was brought to the ED by court order, was very delusional, having disorganized thoughts, and had been in the ED for 2 days before their elopement. PA D recalled Patient #1 making a statement that "I am a radio head and you're going to watch me leave." PA D reported the ACH has changed their process of treating BH patients due to Patient #1's elopement, and now they will be consulting within 24-hours. PA D reported that the ACH's psychiatrist are not on call at night, but they utilized Integrated Telehealth Partners (ITP) (BH care by video) for after-hours or immediate needs. PA D identified that the crisis hall is not okay, because there is not enough room for patients. PA D reported that Patient #1 was allowed to elope, because he was kept in the main ER due to there not being room in the crisis hall for all the BH patients they had. PA D reported that following Patient #1's return to the ED, they were kept in the crisis hallway through the weekend due to their elopement risk, and the inpatient psychiatric provider admitting another violent patient prior to admitting Patient #1 to the inpatient BH unit. Finally, PA D reported that the ED providers usually order medications for patients in the ED, and that Patient #1 was very paranoid about medication and thought their medication was going to kill them, so it was difficult to get them to take medication.

7. During an interview on 6/29/23 at 9:00 AM, RN P recalled caring for Patient #1 on 5/12/23, the day they eloped from the ED. RN P recalled Patient # 1 was in trauma bay 2, delusional, not suicidal or homicidal, was not on their medication, and had been walking around being calm and appropriate. RN P reported Patient #1 was seen by PA D, was told they would have to stay in the hospital, and then they started pacing in the hallway in front of the nurse ' s station. RN P recalled Patient #1 saying they could not be here for three days and felt like running. RN P reported they called the crisis hall to have Patient #1 transferred, but Patient #1 eloped during the call. RN P recalled a tech being at the nurse's station watching Patient #1, and another tech being right there, but Patient #1 bolted through the doors, and the wander guard did not alarm or lock the doors. RN P reported Patient #1 was located by law enforcement, and upon Patient #1's return to the ED they were taken directly to the crisis hall.

8. During an interview on 6/29/23 at 1:00 PM, CNA E recalled working on 5/12/23, the day Patient #1 eloped from the ED. CNA E recalled Patient #1 was upset after talking to the psychiatric provider, because they had to stay in the ACH, they did not want to go back to their room, and was talking about running, not wanting to stay for another three days, and they did not want to be in a room with all the other people. CNA E recalled that Patient #1 was pretending like they were walking to the bathroom when they turned and ran out of the ED. CNA E also reported that the nurse was trying to get Patient #1 moved to the crisis hall when they ran out. CNA E recalled they were standing inside the nurse's station when Patient #1 ran, and CNA E ran after them. Finally, CNA E recalled that Patient #1 was in the man ED in a trauma bay when they arrived to work on 5/12/23.

9. During an interview on 6/28/23 at 1:30 PM, Crisis Team Worker G recalled documenting on Patient #1 ' s elopement from the ED the morning after the incident (5/13/23). Crisis Team Worker G reported they reviewed Patient #1 ' s chart and did not see any documentation from the Crisis Team regarding Patient #1 ' s elopement, so they contacted public safety, and requested they review the video footage of the incident. After public safety reviewed the footage Crisis Team Worker G documented the incident in Patient #1 ' s chart. Crisis Team Worker G recalled that Patient #1 was placed in the crisis hall when they returned following their elopement. Crisis Team Worker G confirmed that Patient #1 was first seen by psychiatry on 5/12/23, and the Crisis team attempted to see Patient #1 on 5/11/23 and 5/12/23, but they were sleeping both times. Finally, Crisis Team Worker G reported that once a court ordered patient is brought to the ACH, they cannot be transferred to another facility.

10. During an interview on 7/5/23 at 1:30 PM, ED Director Q recalled working after Patient #1's elopement from the ED. ED Director Q recalled walking through the event with the ED staff working at the time, and that they reported Patient #1 was pacing in the hall prior to the elopement. ED Director Q reported they did not know when Patient #1 was transferred from the crisis hall into the main ED, but documentation showed Patient #1 was calm, in a better place, and cooperative with staff. ED Director Q acknowledged there was a gap from the time Patient #1 was admitted to the ED (5/10/23 at 4:29 PM) until they were seen by a psychiatric provider (On 5/12/23 at 12:03 PM) and treatment was started (On 5/13/23 at 12:09 PM).