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Based on review of medical records, facility policies and procedures and interviews, the hospital failed to provide an appropriate psychiatric screening for one of one patients (Patient #1) who presented to the facility's dedicated emergency room on November 5, 2021 with lacerations to her wrists and a previously stated intent to harm herself.

Findings included:

Review of Patient Care Report (ambulance report), dated November 5, 2021, revealed "Emergency Medical Services (EMS) requested for a suicidal patient who had cut her wrist. Arrived on location and found patient with lacerations to both wrists. Patient presents conscious and intoxicated. Wounds appear to be self-inflicted lacerations on both wrists. Found in house was half empty bottle of vodka, a short note, possible suicide, a kitchen knife, a check to someone for $11,000 and about 100 cc of blood loss. Also found was an empty bottle of Xanax prescribed in 2017. Pt. stated she did not want to live anymore."

Review of Emergency Department Notes, dated November 5, 2021 from 17:38 to 20:47 revealed but was not limited to the following:

1. History of Present Illness: 73 year old female patient with past medical history of COPD, GERD, hyperlipidemia and depression presents in the emergency department via (local) EMS for evaluation for suicidal ideation. Patient friend called law enforcement who was on the phone with patient and reported that patient did not sound like her usual self. First responder reported when patient walked out of her home he noted patient was bleeding. Per officer patient upset they saved her life. EMS reports that patient expressed suicidal ideation; states she cut herself to kill herself and that "she is alone in this world and wants out." EMS showed a picture that shows patient had about a half a liter of vodka, Xanax bottle with only one pill left also found on scene. Lacerations to bilateral wrists noted at time of encounter.

2. Medical Decision Making Narrative: Turnover to Physician #1 at shift change. Patient with a long history of depression here with attempted suicide with cutting her wrists. Laceration was repaired. ETOH (Alcohol) was 174 (Normal Range was 0-79mg/dL). She endorses taking multiple Xanax several days ago because "I don't want to wake up". And cutting today was an attempted suicide. She is on an Emergency Order of Detention (EOD) from the sheriff's department. She is medically cleared from our standpoint. She is being discharged in their custody.

Review of Notification of Emergency Detention #1 filed by the county sheriff's department, dated 11/05/2021 at 6:34 PM revealed the sheriff's department has legal custody of Patient #1 in order to obtain mental health treatment for Patient #1. This EOD stated the sheriff's office was seeking temporary admission to the local mental health organization.

Review of EOD #2 filed by the county sheriff's department, dated 11/05/2021 at 22:03 revealed the sheriff's department filed a second EOD in order to take Patient #1 to a hospital that provides mental health services directly.

Review of county sheriff's office incident report, dated 11/05/2021 from 16:33 to 16:52 revealed but was not limited to the following: "A deputy responded to a welfare concern. She (Patient #1) had severe lacerations on both wrists, which were self-inflicted. She appeared to be highly intoxicated and refused to answer any questions about what had happened. She was extremely upset that we did not "just let her die". Due to her self-inflicted injuries, she was transported to the local medical hospital for further care. She was placed in "protective custody" due to her mental status. The deputy sheriff remained with her until another deputy sheriff took his place. At approximately 2100, she was medically cleared from the emergency room (ER) and transported to another hospital for mental health treatment."

Review of facility policy and procedure entitled "Plan for Care of Patients with Psychiatric or Substance Abuse Issues", effective 12/03/2021 but originated 04/19/2010, revealed but was not limited to the following: Patients presenting to the hospital with a primary psychiatric behaviors or suicidal ideation (depending on where they present), and prepared for transfer to an appropriate facility (as indicated) where appropriate care can be provided when stable and medically clear. 1. Physician's/staff will request a Mental Health Developmental Disabilities (MHDD) consult after proper medical clearance is obtained. 2. In response to the consult, the MHDD liaison will interview and assess the patient's need for acute behavioral health stabilization. The MHDD liaison will work with the physician, poison control, MHDD, and other outside resources as applicable, to find the appropriate venue (if indicated) for the patient to be treated.

Interview on 04/19/2022 at 1:17 PM with facility administrative staff revealed but was not limited to the following: They indicated they utilize the local MHDD agency for patients needing psychiatric care. They indicated that they did not immediately call the local MHDD to evaluate Patient #1 because her ETOH was 174 and the local MHDD policy states they will only evaluate a patient for psychiatric care if their ETOH is under 100. They stated it would take awhile for her ETOH to be under 100 based on her current number of 174. They further explained that when they explained this policy to the local sheriff's department, they stated that "we have custody of this patient (Patient #1) and we are going to take her to a larger hospital that will see her sooner." They further stated they did not think they had any recourse since the sheriff's office had custody by way of an EOD.

Based on review of complaint, medical records, facility policies and procedures and interviews, hospital #1 failed to provide an appropriate transfer for one of one patients (Patient #1) who presented to the facility's dedicated emergency room on November 5, 2021 with lacerations to her wrists and previously stated intent to harm herself.

Findings included:

Review of complaint, dated 03/07/2022, revealed but was not limited to the following: Patient #1 is a 73 year old female with a history of depression arrived at Hospital #2 via the county sheriff's department under Emergency Detention. There was no Memorandum of Transfer nor administrative acceptance nor physician acceptance. This case questions if Patient #1 was stable for transfer at this time she was brought to Hospital #2 since there was no referral or intervention by the local mental health authority.

Review of Patient Care Report (ambulance report), dated November 5, 2021, revealed "Emergency Medical Services (EMS) requested for a suicidal patient who had cut her wrist. Arrived on location and found patient with lacerations to both wrists. Patient presents conscious and intoxicated. Wounds appear to be self-inflicted lacerations on both wrists. Found in house was half empty bottle of vodka, a short note, possible suicide, a kitchen knife, a check to someone for $11,000 and about 100 cc of blood loss. Also found was an empty bottle of Xanax prescribed in 2017. Pt. stated she did not want to live anymore."

Review of Emergency Department Notes, dated November 5, 2021 from 17:38 to 20:47 revealed but was not limited to the following:

1. History of Present Illness: 73 year old female patient with past medical history of COPD, GERD, hyperlipidemia and depression presents in the emergency department via (local) EMS for evaluation for suicidal ideation. Patient friend called law enforcement who was on the phone with patient and reported that patient did not sound like her usual self. First responder reported when patient walked out of her home he noted patient was bleeding. Per officer patient upset they saved her life. EMS reports that patient expressed suicidal ideation; states she cut herself to kill herself and that "she is alone in this world and wants out." EMS showed a picture that shows patient had about a half a liter of vodka, Xanax bottle with only one pill left also found on scene. Lacerations to bilateral wrists noted at time of encounter.

2. Medical Decision Making Narrative: Turnover to Physician #1 at shift change. Patient with a long history of depression here with attempted suicide with cutting her wrists. Laceration was repaired. ETOH (Alcohol) was 174 (Normal Range was 0-79mg/dL). She endorses taking multiple Xanax several days ago because "I don't want to wake up". And cutting today was an attempted suicide. She is on an Emergency Order of Detention (EOD) from the sheriff's department. She is medically cleared from our standpoint. She is being discharged in their custody.

Review of Notification of Emergency Detention #1 filed by the county sheriff's department, dated 11/05/2021 at 6:34 PM revealed the sheriff's department has legal custody of Patient #1 in order to obtain mental heatlh treatment for Patient #1. This EOD stated the sheriff's office was seeking temporary admission to the local mental health organization.

Review of EOD #2 filed by the county sheriff's department, dated 11/05/2021 at 22:03 revealed the sheriff's department filed a second EOD in order to take Patient #1 to hospital #2 that provides mental health services directly.

Review of county sheriff's office incident report, dated 11/05/2021 from 16:33 to 16:52 revealed but was not limited to the following: "A deputy responded to a welfare concern. She (Patient #1) had severe lacerations on both wrists, which were self-inflicted. She appeared to be highly intoxicated and refused to answer any questions about what had happened. She was extremely upset that we did not "just let her die". Due to her self-inflicted injuries, she was transported to the local medical hospital for further care. She was placed in "protective custody" due to her mental status. The deputy sheriff remained with her until another deputy sheriff took his place. At approximately 2100, she was medically cleared from the emergency room (ER) and transported to hospital #2 for mental health treatment."

Review of facility policy and procedure entitled "Transfer Procedure", last reviewed 10/01/2015 and originated 03/01/2003, revealed but was not limited to the following: "The attending physician will initiate the transfer order to the hospital of choice as the need arises. The Memorandum of Transfer is completed by the nurse transferring the patient. A copy of the patient's medical record from this facility and the Memorandum of Transfer are sent to the hospital in a sealed envelope to maintain patient confidentiality."

Interview on 04/19/2022 at 1:17 PM with facility administrative staff revealed but was not limited to the following: They indicated they utilize the local MHDD agency for patients needing psychiatric care. They indicated that they did not immediately call the local MHDD to evaluate Patient #1 because her ETOH was 174 and the local MHDD policy states they will only evaluate a patient for psychiatric care if their ETOH is under 100. They stated it would take awhile for her ETOH to be under 100 based on her current number of 174. They further explained that when they explained this policy to the local sheriff's department, they stated that "we have custody of this patient (Patient #1) and we are going to take her to a larger hospital that will see her sooner." They stated that when the sheriff's office takes custody of a patient, the emergency department personnel may not always know where the sheriff's department takes them. They further stated they did not think they had any recourse since the sheriff's office had custody by way of an EOD.