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Based on a review of documentation, the facility failed to provide an appropriate medical screening examination, as evidence by failing to ensure a patient presenting with a history of dementia and schizophrenia, exhibiting agitation, that appeared to lack insight to ensure their own well-being, received a complete neurological evaluation or psychiatric evaluation/consultation at the facility.

The facility also failed to treat and manage the patient's high blood pressure in a timely manner upon their initial presentation to the facility on 05/26/23, not administered medication until 05/27/23.

The failure to properly medically screen (which included screening for mental health) and treat the patient's blood pressure, put this patient's safety and health at risk.

Finding included:

Patient #1 (a 73-year-old male) initially presented to the facility emergency department (ED) accompanied by a police officer on 05/26/23 at 1:57 AM with a chief complaint of, "Aggressive Behavior". Presented with "w/ AMS and agitation. Pt was in the process of admitting to a local NH (Nursing Home) when he became agitated and combative. NH refused to admit him and sent him here."

NOTIFICATION-EMERGENCY-DETENTION dated 05/25/23 at 5:57 PM, regarding Patient #1 stated in part, "The subject, [Patient #1], according to [Nursing home facility name] has been, diagnosed with Alzheimer's and schizophrenia. [Patient #1] was in the middle of being transported from [facility name] nursing home in San Antonio, due to being a flight risk, with him recently escaping, and for memory care. [Nursing home facility name] care facility stated he did not-want to stay and due to him not being admitted yet they could not keep him there. After being in the sheriff's office care for several hours trying to determine what action to take next it was determined-to complete an EDO. [Patient #1] presents a danger to himself, due to not currently knowing where he is, believing he is in San Antonio, attempted to make payment with AARP card, and is adament [sic] he is going home in Little Rock Arkansas (even though he cannot provide me with one name of anyone he knows there) and has now been tere [sic] since July."

Patient #1 was triaged on 05/26/23 at 2:18 AM. The triage note stated, "Patient arrives to ER room accompanied by police officer. Patient presents alert, oriented to self only. Patient is agitated and verbalizes multiple times that he does not want to be here and would rather be 'walking the streets.' Police officer reports patient arrived at nursing home in [city name] today and was refused admission by staff due to aggressive behavior. Patient is uncooperative and declines interventions other than VS. Patient reports he is feeling well. Denies CP, SOB, n/v/d, fever, chills, cough. Patient is otherwise well appearing, dressed well."

A History of Present Illness (HPI) was completed on patient #1 that stated they were presenting for alerted mental status and agitation. There is no psychiatric evaluation noted by emergency room physician for this patient on the HPI note or in the Emergency Room Record for 05/26/23 or 05/27/23.

Documentation reflected the emergency room physician and nursing staff attempted to obtain a consultation with the local mental health authority due to the emergency detention in place for this patient. A nurse note on 05/27/23 at 3:44 PM stated the local mental health authority, "called back and stated they do not have any one on staff that could determine mental capacity ..."

Case management was unsuccessful in obtaining placement in a mental health facility for patient #1. Case management contacted approximately 12 mental health facilities that declined the patent or did not have beds available at the time.

Multiple notes in the record document the patients' history of Alzheimer's and demonstrated agitation while in the Emergency Room.
Emergency Room Physician note on 05/26/23 at 2:05 PM stated in part, "Pt without SI/HI or self-harm, hasn't been violent. Will discontinue direct observation." Of note, no psychiatric evaluation/consultation was completed to release the Emergency Detention or continued the Emergency Detention until placement at a mental health facility could be found for this patient. Also no plan for safety regarding this patient was documented.

Emergency Room Physician note on 05/27/23 at 4:47 PM stated, "Pt was offered housing at nursing home where he will be taken care of and has declined. If he is not amenable to housing or treatment, but he has medical capacity there is nothing we can do for him today. I consulted the hospitalist Dr [Name], but since he is not interested in medical management of his BP he was not accepted for admission. Will discharge him, and he was invited to return and we would help arrange nursing home placement if he changes his mind and he voiced understanding."

Emergency Room Physician note on 05/27/23 at 5:59 PM stated, "Pt EDO now > 48 hours and has expired. He is calm and cooperative, hasn't shown any aggression. I left a VM with his son to try to get him a ride to his car in SA. He was again offered housing placement and has declined. He says he would rather wait in the waiting room. Will discharge him then."
Patient #1 left facility on 5/27/23 at 3:06 PM. Patient #1 was discharged on 5/27/23 at 6:34 PM. Discharge instructions have a diagnosis of hypertension and schizophrenia. The patient was discharged despite the involuntary hold of the Emergency Detention dated 05/25/23 at 5:57 PM, that would have remained in effect at the time they left the facility 05/27/23 at 3:06 PM.

Initial vital signs were taken for Patient #1 on 05/26/23 at 2:18 AM with a hypertensive blood pressure of 212/128 noted. It was noted several times the patient declined to take blood pressure medications, the last blood pressure recorded for this patient prior to leaving the facility was noted as, "Pt's last BP is 180/118".

Patient #1 had Hydralazine ordered for their blood pressure but it was not administered. Patient #1 did take oral metoprolol on 5/27/23 at 2:52 PM, this was the first medication administered for their documented hypertension

Patient #1 presented to the facility a second time, accompanied by a police officer again on 05/28/23 at 6:50 PM with a chief complaint of "Delusional".

Emergency Room Physician note on 05/29/23 at 9:10 AM stated, "TOC in ED from Dr [Name] , I am familiar with patient, he was being transported from one nursing home in SA to another, but refused to be admitted. Police were called and EDO'd him to {another mental health facility] but instead he was brought to the ER for clearance. He has been cooperative, nonviolent, he was even discharged two days ago and stayed under shelter, no evidence that he will harm himself in traffic, etc. He has known dementia and schizophrenia but is able to identify the risk in choosing not to treat his hypertension. We spoke with family who are not willing to take patient. His son reported he has medical decision making and they do not have MPOA, but allegedly he was deemed not to have financial decision making by a court. No documents of medical incapacity are available - no OPC on file. He has delusions and there is concern as with any psychiatric patient that he could worsen, but there is no evidence of imminent harm as he has not tried to run into traffic, harm himself or others to warrant a removal of liberties, however in respect of the APOWW and EDO, I will defer to a psychiatric professional if we can obtain one. None are available at this facility, and thus far we have been unable to obtain a transfer acceptance to any psych facility. His EDO will expire on next business day Tuesday, May 30th at 4pm."

Per HPI by the Emergency Room Physician done 5/28/23 at 8:01 PM, " "73M w/ dementia and schizophrenia has returned with PD after being discharged yesterday. He has an EDO. He is refusing labs and all medications. Pt has been rejected by psych hospitals 2/2 HTN, but pt adamantly refuses to take blood pressure medicine. He is quite pleasant but does start to get agitated with discussions of medication or nursing homes. He can easily verbally redirected. His family is not actively involved in his life. Pt was incarcerated until recently. He denies having any symptoms.""

Again, there is no psychiatric evaluation noted by emergency room physician for this patient on the HPI note or in the Emergency Room Record for 05/28/23.

Nurse note (date of service) 05/29/23 at 3:00 PM stated, "Pt came out of room and stated he was leaving. Pt walked out of the ER and outside. Security notified of patient leaving. Pt is calm with steady gait. Llano Sheriff's dept called to notify of patient leaving and they state his EDO has expired and will not be coming to get him."

Nursing note (date of service) 05/29/23 at 3:03 PM stated, "Pt states he wants to leave the ED. Instructed by MD and charge nurse to allow pt to leave."

Emergency Room Physician note signed by the physcian on 06/09/23 at 4:26 PM stated in part, "TOC in ED to Dr. [name] at 2:00 PM on 5/29/23, pt eloped sometime after. Sheriff was called and did not come to pick up patient since he was voluntary at that point."

Patient #1's Emergency Detention order (involuntary hold) would have been in effect until 05/30/23 at 1600 unless the patient was cleared or released after a mental health evaluation/assessment was completed at the facility.

Patient #1 was discharged twice from the facility without complete neurologic evaluation or psychiatric evaluation/consultation being performed to address capacity or mental status. Medical capacity was referenced in the record, but mental health capacity was not evaluated or addressed for this patient.