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Based on review of documentation and interviews, the facility failed to ensure patients presenting to the Emergency department (ED) with suicidal risk received an appropriate medical screening exam prior to being discharged and escorted out of the hospital by police. In 1 of 20 sampled patients (Patient #5).

An EMTALA (Emergency Medical Treatment and Active Labor Act) requires all patients seeking treatment at an Emergency Department to receive a Medical Screening Evaluation (MSE) to determine if am Emergency Medical Condition (EMC) is present. At the time patient #5 was discharged on 04/19/2024, and removed by police, he/she was displaying abnormal and agitated behavior indicative of potential ongoing emergency medical condition, as indicated by requesting to leave but then refusing to leave. Patient #5 was described by the discharging physician (MD #4) as "very agitated", and up to that point was still under suicidal precautions. The hospital failed to provide evidence that an appropriate medical screening evaluation was completed to rule out if an Emergency Medical Condition persisted prior to discharge, as Patient #5 continued to display abnormal behaviors.

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with behavioral crisis and psychological complications.

Refer to Tag A2406

Based on review of documentation, interviews, and review of security video footage, it was determined that the facility failed to provide Patient #5, an appropriate medical screening exam at the facility's Emergency Department (ED) prior to discharge on 04/19/2024.

Findings:

Facility policy entitled "EMTALA" last revised 02/14/2023, stated in part, " It is the purpose of this policy to ensure that:
(1) all patients who come to the hospital requesting emergency services receive an
appropriate medical screening examination to determine if an emergency medical
condition exists;
(2) patients with an emergency medical condition (as defined below) are stabilized ..."

"2.1 Medical Screening Examinations Generally.
MMC/SMHC must provide an appropriate medical screening examination (MSE) to every
individual covered by EMTALA, as defined in Section 1 of this Policy, based on the person's
medical circumstances and condition and without regard to the individual's insurance status or
ability to pay for the examination."

"2.2 What is a Medical Screening Examination (MSE)? A medical screening examination (MSE) is an examination by qualified, designated MMC/SMHC [Maine Medical Center/Southern Maine Health Care] personnel to determine with reasonable clinical confidence whether an individual has an emergency medical condition (EMC). The extent of the MSE is based upon the judgment and discretion of the physician or advanced practice provider (APP) as to what is necessary to accurately determine whether the individual does or does not have an EMC ..."

"2.3 What is an Emergency Medical Condition (EMC)?
An Emergency Medical Condition (EMC) is defined as a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or
symptoms of substance abuse) such that the absence of immediate medical attention could
reasonably be expected to result in (a) placing the health of the individual (or with respect to
pregnant women, the health of the woman or her unborn child) in serious jeopardy; or (b)
serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part."

"2.3.2 Psychiatric Patients.
A psychiatric patient is considered to have an EMC if either (a) acute psychiatric or acute substance abuse symptoms are manifested; or (b) the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others."

"3.2 Definition of Stabilized. A patient with an EMC will be considered stabilized if the treating physician has determined within reasonable clinical confidence that the patient is expected to leave the hospital (via either discharge or transfer to another facility) with no material deterioration in his or her medical condition."

"3.2.2 Psychiatric Patients. In the case of an individual who is suffering from a psychiatric condition(s), the individual is considered to be stable when he or she is protected and prevented from injuring himself/herself or others."

On 04/19/2024 at approximately 10:10 AM, patient #5 presented to the Emergency Department (ED) at Maine Medical Center accompanied by law enforcement. The triage note by RN #1 stated, "Pt presents from [Recovery home] for crisis evaluation. Increased SI [suicidal ideation], and paranoia. Denies plan. Pt is agitated and fidgeting on arrival, but cooperative with care at this time. Denies HI [homicidal ideation] at this time. Pt denies drug and alcohol use today. Endorses hallucinations, but states this is a constant problem for [him/her]." The triage note included a Columbia Suicide Scale (a suicide risk assessment tool that supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs) completed by RN #1. Patient #5 was placed in a hallway bed in direct site of the nursing station, belongings secured by security and the patient was also provided set of paper scrubs to wear.

On 04/19/2024 at approximately 10:36 AM, patient #5 was seen for an examination by MD #1 and MD #2. Patient medical record includes history of: Amphetamine-induced psychotic disorder with hallucinations, Psychosis, Schizoaffective disorder, bipolar type, and, Stimulant-induced disorder (Common psychological complications of stimulant use disorders include psychosis, depression, hypervigilance, and anxiety.) The physician note by MD#1 included: " ... presents from Police Department behavioral health unit after being found acutely agitated. History is vague. At this time [he/she] does state that [he/she] uses alcohol and meth but is unable to provide a timeframe of use, at times nods yes to use within the past 24 hours but is unable to speak for self. Says yes to increased hallucinations, auditory and visual. Says no to suicidal ideation. Says that [he/she] hurts all specific details as to where in [his/her] body this is. Asked if [he/she] would like some medicine to help calm down [he/she] says if doctors thinks it is necessary that is fine ..."

Additionally, a physical examination was performed, and laboratory blood testing ordered.
Review of systems included: "Psychiatric/Behavioral: Positive for agitation and hallucinations. Negative for suicidal ideas. The patient is hyperactive."

The examination included the following statement: "Psychiatric: Comments: No suicidal or homicidal ideation. Endorses auditory and visual hallucinations. Behavior is abnormal, interrupted by whole body discoordinated spasms, asymmetrically and shaking in bed. Stares off into space while talking."

MD #2 ordered "OLANZapine (ZyPREXA) injection 5 mg" (a medication used to treat mental disorders, including schizophrenia and bipolar disorder and associated agitation) at 10:42 AM. To treat patient #5's anxiety and agitation. This medication was administered at 10:51 AM.

The patient record indicated multiple safety checks and medical/behavioral assessments by nursing staff throughout Patient #5's time in the ED. Patient #5 remained on suicide precautions and hourly rounding during the time in the ED. At 3:27 PM nursing note by RN #2 reports; "Pt awake, crying, appears upset and asking for food." Note indicates the patient remained in an "agitated state".

MD #4's note at 3:45 PM stated: "I received this patient in signout. Patient is very agitated and wanting a cigarette. I reassessed the patient [he/she] is denying any SI or HI. [He/She] stated adamantly that [he/she] feels safe to leave and states over and over again that [he/she] "just wants a cigarette." Patient discharged from the ED HDS [hemodynamically stable].

Medical record note by RN #2 indicated at approximately 4:28 PM on 04/19/2024, patient #5, "Pt refuses to leave after [he/she] requested a taxi voucher, which was provided. Discharge papers were provided. Pt continues to scream very loudly that [he/she] wants a cigarette. Pt refuses to leave. Dr [MD #3] was contacted. Security returned all personal belongings to pt." Another nursing note by RN #3 reported, "Pt refusing to leave after given taxi voucher. Dr. [MD #4] at bedside and pt still refusing. This RN spoke with Dr. [MD #4] and agreed to call PD [police] as pt not leaving." Patient #5 was discharged from the Emergency Department escorted by the local police department at approximately 5:00 PM on 04/19/2024.

Review of security video shows patient escorted out of the ED by police. Patient appears to be yelling and staff appear to be shielding other patients from patient #5 as he/she exits the ED. Patient #5 appears to be yelling and stomping feet while leaving. Once outside the ED, patient #5 attempts to reenter the waiting room when in the entry vestibule, dropping items, circling back, continues to be wearing scrubs (at least the top) and blood pressure cuff is still attached to his/her arm.

The information obtained in the patient record was additionally verified through interviews with various emergency department staff throughout the course of the complaint survey.

Interviews with Chair of ED Psychiatry, (MD #5), who stated all patients receive a Columbia Suicide Scale which is completed by an RN. An assessment by an Emergency Department physician or PA will complete an assessment with "key questions" to immediately evaluate their level of safety risk. At this point the patient may stay as a 1:1 observation and referred to a team psychiatrist or a licensed clinical social worker who will evaluate and discuss case with a psychiatrist. Psychiatrist may or may not evaluate patient directly. MD #5 stated that when the patient is ready to be discharged, must agree to a "safety plan". The safety plan includes seeking help.

Interview with RN #2 on 05/03/2024 at approximately 11:14 AM, reported, "She recalled that the patient was very erratic, wanting to stay, but not wanting care. The patient was yelling and calling the nurse names and swinging at the nurse." Additionally; "The patient kept asking for a cigarette, calling the staff names. offered the patient a nicotine patch, which was offered but refused and said [he/she] wanted to leave."

Patient #5 was discharged without evidence of an appropriate medical screening re-examination to determine if an emergency medical condition (EMC) continued/worsened, based on the documented change in his/her signs and symptoms. The hospital's EMTALA policy states in part: "MMC/SMHC must provide an appropriate medical screening examination (MSE) to every individual covered by EMTALA."

The triage nurse note described him/her as presenting at time of admission with increased suicidal ideation, paranoia, auditory and visual hallucinations. Patient #5's behavior was described by MD #1 as, " ...abnormal, interrupted by whole body discoordinated spasms, asymmetrically and shaking in bed. Stares off into space while talking."

However, at the time of discharge, he/she was described as "very agitated", "screaming loudly" and "refusing to leave the emergency department". Security video displayed him/her yelling and stomping feet while leaving accompanied by police and security, making attempts to reenter the emergency department, dropping items, and circling back, with uncoordinated movements.