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Based on policy review, ambulance run report review, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for Patient #2 who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 02/19/2021. This had the potential to affect all patients served.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's DED for psychiatric evaluation on 02/19/2021.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy review, ambulance run report review, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's Dedicated Emergency Department (DED) for psychiatric evaluation on 02/19/2021. This had the potential to affect all patients served.

The findings included:

Review of facility policy titled "Suicide Risk Assessment" effective 09/21/2020 revealed, "...When patients are assessed to be at a moderate or high risk for suicide, a plan for intervention is made. The plan is documented in the progress note. Documentation may include consultation with psychiatrist, increasing the frequency of the therapy session, psychiatrist assessment, admission to facility-based crisis, or voluntary/involuntary admission to a psychiatric facility. The ultimate determination of the appropriate response when suicidal ideation or behavior is present depends on the judgement of the individual provider ..."

Patient #2 was a 29-year-old male who presented to the DED on 02/19/2021 at 2053 via EMS (Emergency Medical Services) for a psychiatric evaluation. Review of an ambulance run report written by Paramedic #1 on 02/19/2021 (unknown time) revealed, "...Upon arrival, patient found standing at the residence front doorway, accompanied by (named Police Department) and home caregiver. Patient's caregiver states patient complained of 'feeling bad' and that he was beginning to want to kill himself. Caregiver states patient requested to be taken to the hospital for help. Patient denies having an exact plan to kill himself. Patient presents breathing normally and speaking in complete sentences. Patient presents with good skin color, temp. and condition. Patient walk assisted to ambulance and placed on stretcher ..."

Review revealed Patient #2 was not his own legal guardian, noting his legal guardian was Adult Legal Guardian Organization (ALGO) #1.

A Medical Screening Exam (MSE) was initiated by Medical Doctor (MD) #1 at 2057. Review of an Emergency Department (ED) provider note written by MD #1 on 02/20/2021 at 0438 revealed, "...29-year-old male with history of schizophrenia, from group home, frequent evaluations for SI (Suicidal Ideation), multiple hospitalizations, previous suicide attempt by cutting his wrists, states he was feeling suicidal and wanted further evaluation, specifically requested immediate admission to behavioral health, patient has no active plan at this time, is elusive when answering questions directly about his suicidal intent, states he is medication compliant, has no other complaints or concerns at this time ... Review of Systems ... Psychiatric/Behavioral: Positive for behavioral problems, dysphoric mood, self-injury, sleep disturbance and suicidal ideas. Negative for agitation and confusion ... Physical Exam ... Psychiatric: Attention and Perception ... normal ... Mood is depressed. Affect is blunt and flat ... Speech is normal ... Behavior is withdrawn. Behavior is cooperative ... Thought content is not paranoid or delusional. Thought content includes suicidal ideation. Thought content does not include homicidal ideation. Thought content does not include homicidal or suicidal plan ... Cognition and memory normal. ED Course & MDM ... Sat (Saturday) Feb (February) 20, 2021 0436 After sleeping in the emergency department patient states he feels very well, has no thought of self-harm, complete resolution of his previous suicidal thoughts, feels safe with disposition home ... MDM ... male who presented with very vague suicidal thoughts without any plan, patient was amenable to sleeping in the emergency department with reevaluation. At time of reevaluation patient states his head is now completely clear, he feels well overall, has no thoughts of self-harm, contracts for safety, feels safe for disposition home..." Review of a note written by Registered Nurse (RN) #1 on 02/20/2021 at 0500 revealed, "Psych assessment started at 0420 and was completed at 0434. Attempted to call (Named Case Worker from Patient #2's group home and telephone number) for further information, but received no answer." Laboratory orders included a Urinalysis, Acetaminophen level, Salicylate level, Ethanol level, Urine Drug Screen, and a Complete Blood Count. No blood sample based laboratory study resulted as clinically significant.

The Urinalysis and Urine Drug Screen were not performed noting the orders were discontinued on 02/20/2021 at 0534.

Patient #2 was discharged from the DED on 02/20/2021 at 0556. Review of Patient #2's discharge instructions revealed, "...Schedule an appointment with (Named County) Response Center as soon as possible for a visit in 1 day ..." Review revealed no documentation of whether Patient #2 was alone at the time of discharge, noting he signed his discharge instructions.

Telephone interview was conducted with MD #1 on 04/13/2021 at 0949. Interview revealed upon chart review MD #1 recalled Patient #2. Interview revealed while not documented, MD #1 always reviews previous DED admissions and psychiatric consults if the patient is a psychiatric patient that has been to the facility before. Patient #2 had a psychiatric consult in Hospital A's DED on 02/10/2021, 9 days prior to his 02/19/2021 DED visit. On 02/10/2021 Patient #2 had similar DED presentation of poor mood or thoughts of suicide; and was cleared for discharge then. Interview revealed on 02/19/2020, during MD #1's initial evaluation Patient #2 wanted to sleep which he was allowed to do, and at approximately 0430 on 02/20/2021 MD #1 re-evaluated Patient #2 and he was in good spirits with an improved mood and no longer verbalized suicidal or self-harm thoughts, no delusions, and no thoughts of harming others. Interview revealed he was medically clear and safe for discharge, and Patient #2 himself verbalized he was safe for discharge. Interview revealed medical providers do not take part in arranging post discharge transport for patients leaving the DED. Repeat telephone interview was conducted with MD #1 on 04/14/2021 at 1748. MD #1 advised he did not realize the ordered Urinalysis and Urine Drug Screen laboratory studies had not been performed. Interview revealed the results would have been irrelevant to Patient #2's ED Disposition. Interview revealed his cognition was normal for him at the time of discharge.

Telephone interview was conducted with RN #1 on 04/14/2021 at 0955. RN #1 vaguely recalled Patient #2 after a chart review. (ALGO #1) was charted as Patient #2' legal guardian. The person RN #1 attempted to contact on the morning of 02/20/2021 was the Case Worker "over the group home." Interview revealed there was no answer at the number for the group home, and there was no option to leave a voicemail, or a message with an alternate number to attempt to contact regarding his discharge. Interview revealed RN #1 did not discharge Patient #2.

The Registered Nurse that provided Patient #2 with his discharge instructions and discharged him was not available for interview.

Review revealed Patient #2 returned to Hospital A's DED via EMS on 02/23/2021 at 0508. Review of an ambulance run report written by Paramedic #2 on 02/23/2021 at 0509 revealed, "... dispatched routine traffic to an address where Police Department (PD) has a missing persons that is a 29 yr old male missing from a group home for 3 days. Upon arrival, pt (patient) found standing with PD outside of a resident's of this address and alerted PD. Pt is COAx3 with a GCS (Glasgow Comas Scale - common scoring system used to describe the level of consciousness) of 14. Unsure if this pt norm. Pt admits to using 'crack an hour or so' prior to this event. Pt pupils are constricted with no reaction. Pt ambulates and boards truck with assistance and sits semi-fowlers on stretcher ... EMS notes pt shivering with cold hands but warm core ... Pt has no other c/o pain while en route. Pt lay back and closes eyes and tries to sleep. Pt transported without incident and with no significant changes to condition ..."

Review of a note written by RN #2 on 02/23/2021 at 0515 revealed, "Patient brought in by (named EMS Agency) after he was found sleeping in a backyard. Residents of the home denied knowing patient. Patient admitted to (Law Enforcement Agency) on scene that he left his group home 3 days ago. Patient also stated that he used crack. Medic stated that patient was shivering and c/o generalized abdominal pain. Admitted to medic that he always has suicidal thoughts. Patient denies having any SI/HI thoughts. Patient denies any pain. Patient c/o feeling cold."

Patient #2's DED Disposition was set to Discharge by DO #1 on 02/23/2021 at 0530. Review of a note written by RN #2 on 02/23/2021 at 0543 revealed, "Patient is a resident of (ALGO #1). Spoke to (Named Employee), the after hours contact (telephone number) list for patient. (Named Employee) states that she will send some on (sic) for the patient." Review revealed his discharge instructions were signed by a group home staff member, and Patient #2 left Hospital A on 02/23/2021 at 0944.

Patient #2 presented to Hospital B's DED via private vehicle on 02/23/2021 at 1324. Review of a note written by RN #4 on 02/23/2021 at 1352 revealed, "Pt reported to have been d/c from (Hospital A) and his group home was not notified. Pt was out in the streets for 3 days before being found and taken back to (Hospital A). Pt has not been on any of his medications and is acting a little off per care giver. Pt is also fatigued and a little confused at this time..." Review of a Provider Note written by MD #2 on 02/23/2021 at 2038 revealed, "...Chief Complaint Patient presents with Altered Mental Status Caregiver states that patient was seen at (Hospital A) on 2/19 for suicidal ideations without a plan. Pt was discharged but the group home was not contacted. Caregiver reports that patient was discharged and 'do not know where he went."

Patient #2 did not receive an appropriate medical screening examination, as he was discharged 02/20/2021 without notifying his legal guardian at this group home. Patient #2 was missing for three days, sleeping in the backyard of someone's home, prior to being returned to the ED on 02/23/2021.