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Based on interviews, review of the Emergency Medical Treatment & Labor Act (EMTALA) Log, medical record review, policy review and video review, the facility failed to provide stabilizing treatment within the facility's capacity and capability for two (#1 and #2) psychiatric Emergency Department (ED) patients out of 24 patients reviewed. The facility arranged for two psychiatric patients (#1 and #2) to be transported together on the same ambulance to Hospital B. Both patients eloped from the ambulance prior to arrival at Hospital B. The facility had the capacity and capability to admit both Patient #1 and Patient #2 to their pyschiatric unit. The ED had an average of 7,463 emergency visits per month and transferred an average of 85 patients per month. The facility census was 457.

Refer to A-2409 for additional information.

Based on interview, record review, and policy review, the facility failed to stabilize two patients (#1 and #2) within the hospital's capacity and capability, when the patients presented to the Emergency Department (ED) with a psychiatric emergency. The facility failed to initiate measures available within their capacity and capability to prevent the two patients from elopement (a patient who is physically, mentally, emotionally and/or chemically impaired wanders or walks away, in this case from the ambulance while in transport to hospital B unsupervised), when both patients were at risk for elopement. The facility had the capacity to admit both patients to their psychiatric facility. A total of 24 patient ED records were reviewed out of a sample selected from 09/28/17 through 10/09/17. The ED had an average of 7,462 emergency visits per month and transferred approximately 85 patients a month. The facility census was 457.

Findings included:

1. Review of the facility's policy titled, "Definition of Emergency Medical Condition in the Emergency Trauma Center," revised 06/2016, showed that:
- 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 result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
- Serious impairment to bodily functions; and
- Serious dysfunction of any bodily organ or part.
-With respect to Behavioral Health Condition:
- Patient demonstrates symptoms of a mental disorder and is a danger to self, others or property;
- Patient's symptoms of a mental disorder prevents him/her to care for self;
- Patient's symptoms of a mental disorder have not responded to less intensive interventions (outpatient treatment, medications); and
- Patient demonstrates symptoms of a mental disorder secondary to substance abuse and the patient is medically unstable.

2. Review of the facility's policy titled, "Patient Stabilization in the Emergency Trauma Center," revised 06/2016, showed that:
- To ensure that all patients determined to have an emergency medical condition shall be stabilized as required stated under EMTALA (Emergency Medical Treatment and Labor Act) obligations.
- Stabilization, with respect to an emergency medical condition, means to either provide such medical treatment of the condition 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.
- For purposes of transferring a patient with a psychiatric condition between facilities, the patient is considered to be stable when he/she is protected and prevented from injuring himself/herself or others. This includes the duration of transport to the outside facility. The transferring physician anticipates any reasonably foreseeable complication of that condition, and treat immediately prior to transport or provide others to be carried out in the event of a change in the patient's behavior.

3. Review of Patient #1's medical chart showed he arrived in the ED accompanied by law enforcement on 09/28/17 at 2:25 AM with an affidavit to support a 96 hour hold. Review of the affidavit completed by law enforcement showed patient # 1 stated he "wants to end it all"; " cut his left wrist with a razor"; "when asked if he wanted to go to the hospital, patient # 1 stated no, I want to kill myself"; patient # 1 stated "talking him into the hospital would just prolong him killing himself." The medical record did not contain evidence that the hospital filed an application with the court for an involuntary 96 hour detention.

Further documentation in the medical record showed that patient # 1's past history included homelessness and abuse of Marijuana (a psychoactive drug) and methampethamine (an illegal drug). The ED staff placed patient # 1 in ED room # 27 (a room reserved for patients with psychiatric illnesses) for seclusion and continuous video monitoring.

Review of the ED triage notes documented by Registered Nurse (RN) X showed that the patient stated he wanted to kill himself and attempted to do so with a razor blade and that when he got out (of the hospital) he would finish the job. He stated that he had a plan but would not elaborate.

Review of the Medical Screening Examination performed by ED Physician X, showed the patient admitted to suicidal ideation with plans to hang and cut himself. The patient also reported depression and hopelessness. The patient's lab showed that he was was positive for Amphetamines (synthetic psychoactive drug) and Cannabinoids (the chemical compounds which are secreted by the marijuana flower). Staff X requested a Mental Health Examination (MHE) by the Psychiatric Examination Nurse (PENS).

At 5:27 a.m. the psychiatric examination nurse V documented in the medical record that patient # 1 is depressed, homeless and "lost the girl that I love." "States he will finish the job." Further documentation showed patient # 1 had a history of a prior suicide attempt by drinking bleach, had post-traumatic syndrome from being assaulted and repeatedly stabbed in 2014, engaging in high risk behaviors, highly impulsive behavior and a history of substance abuse. At 6:00 a.m. psychiatric examination nurse V documented contact with on-call psychiatrist E who determined the patient required transfer to another hospital for inpatient admission.

At 9:15 a.m. the ED nurse documented that patient # 1 was resting quietly with a blanket over his head. When asked if he needed anything, the patient responsed "a bullet." "You guys are just delaying this."

At 12:01 p.m. documentation showed that Hospital B accepted Mercy Hospital Springfield's transfer request.

At 3:39 p.m. documentation showed the hospital discontinued the order to conduct every 15 minute restraint monitoring and continuous observation of patient # 1. Further documentation showed the crew for the hospital's owned and operated ambulance arrived at the patient's bedside for transport to Hospital C. The medical record did not contain evidence that patient # 1's emergency medical condition had been stabilized within the hospital's capabilities and capacity prior to transport to Hospital C.

During an interview on 10/12/17 at 7:25 AM, Staff V, stated that she performed the mental health assessment on Patient #1. She stated that he had been medicated for his agitation before she saw him. She stated that he was at high risk for suicide and continued to voice suicidal thoughts. She felt he was an elopement risk. She stated that she did not remember if she reported that to his primary nurse.

Review of the hospital's census for psychiatric unit A showed an inpatient census of 6 on 9/28/17 and 9 empty beds, and a census of 11 on psychiatric unit B with 11 empty beds.

4. Review of Patient #2's medical chart showed he arrived at the facility by ambulance with law enforcement on 09/27/17 at 7:29 PM after they found him in a tree with a noose around his neck, threatening to commit suicide. Documentation showed the police officer indicated the patient was heavily intoxicated and incoherent and that the patient was placed on a 96 hour hold for safety precautions. The medical record did not contain evidence the hospital filed an application with the court for an involuntary 96 hour detention. ED staff placed patient # 2 in ED room #25 (a room reserved for patients with psychiatric illnesses) for seclusion and continuous video monitoring.

At 8:31 p.m. the ED nurse documented the patient was becoming increasingly agitated and requesting to leave the hospital. At 8:44 p.m. further documentation showed the patient "remains agitated requesting his attorney." The patient stood in his doorway, refused to enter his room, refused to change into green scrubs and refused a blood draw all while behaving in an aggressive and volatile manner. The ED nurse documented s/he was able to verbally de-escalate the patient.

At 8:41 p.m. documentation in the medical record showed patient # 2 received an intramuscular (IM) injection of Haldol 5mg (anti-psychotic medication).

On 9/28/17 at 12:01 a.m. documentation showed the patient became agitated and stated "I have to go to work tomorrow." At 12:37 a.m. an ED physician S documented that the patient became more belligerent and was out in the hall yelling "something is going to [profanity] happen." Further documentation by ED physician S showed that the patient was verbally/physically threatening.

At 12:41 a.m. documentation showed patient # 2 received an IM injection of Bendaryl 25mg and Ativan 2mg (anti-anxiety medication).

The psychiatric examination nurse V documented at 1:48 a.m. that patient # 2 was at a high risk for suicide per the Columbia Suicide Risk Severity Scale (CSRSS) and was at a high risk for violence per the Broset Score (a list of questions which assesses confusion, irritability, boisterness, verbal threats, physical threats and attacks on objects as either present or absent).

At 2:25 a.m. the psychiatric examination nurse V documented she contacted the on-call Psychiatrist E who determined the patient required transfer to another hospital.
Documentation in the medical record showed that staff began the process to arrange a transfer with Hospital B and C.

At 7:58 a.m. documentation in the medical record showed that patient # 2 continued to be agitated because he could not leave the hospital.

At 12:01 p.m. documentation showed that Hospital C accepted Mercy Hospital Springfield's transfer request.

At 2:22 p.m. the ED nurse documented patient # 2 signed the form for transfer to Hospital C.

At 3:40 p.m. documentation showed the ambulance crew for Mercy Hospital Springfield's owned and operated ambulance arrived at patient # 2's bedside for transport to Hospital C prior to receiving treatment to stabilize his emergency medical condition.

Review of the hospital's owned and operated ambulance trip report showed that the ambulance crew assisted patient # 1 and patient # 2 into the back of the ambulance for transport to Hospital C at 3:39 p.m. on 9/28/17.

Further documentation showed that when the ambulance crew began their assessment, patient # 1 became agitated and stated "You are holding me against my [expletive] will just like the hospital." Documentation showed the ambulance crew tried to de-escalate patient # 1 without success. "During this time I also sensed that patient # 2 was becoming increasingly upset as well by his body movements." "Patient # 2 asked 'How am I supposed to get back home if you're taking me to [hospital C, located over 75 miles away]." "I told him that the hospital should have something in place to ensure he got home but I was uncertain for sure." "This made the man increasingly upset as well." Further documentation showed the ambulance crew became uncomfortable and felt unsafe ... "I shouted at the driver to pull the ambulance over right now and stop!" "We came to a stop on the road where I opened the door and both patients rushed passed me and took off down the road."

Information obtained by the State agency indicated law enforcement was unable to locate either patient, and their whereabouts remain unknown.

During an interview on 10/12/17 at 7:25 AM Staff V, stated that patient # 2 had been in the ED for several hours and she made her assessment after he had been medicated for agitation. She said that he stated he was not suicidal. She telephoned the girlfriend who confirmed the patient had made statements about hanging himself. She stated the on-call psychiatrist agreed the patient should be admitted.

The facility failed to provide stabilizing treatment for Patient #1's and Patient #2's psychiatric emergency. The facility's Psychiatric Units A and B showed the facility had open beds available for admission or could have admitted the patients to an acute medical/surgical unit until a psychiatric bed became available.








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