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Based on a review of emergency department (ED) medical records, facility policy, and interview, Hospital A failed to perform and document an appropriate medical screening examination (MSE) for Patient #1 and Patient #2 to include a full psychiatric evaluation by qualified medical personnel for patients experiencing a psychiatric emergency. Patient #2 was permitted to sign out AMA (against medical advice) inappropriately while experiencing an acute emergency medical condition.

Findings included:

1. Patient #1:
Patient #1 presented to the Emergency Department (ED) on a stretcher at Facility A via EMS with a Parker County Sheriff's Deputy following behind the EMS transport vehicle on 06/10/2019 at 4:34 PM after trying to hurt herself by taking "a handful" of aspirin. There was no suicide risk assessment documented.

Parker County, Sheriff's Deputy, escorted Patient #1 from the time of admission to Facility A through the time of her discharge from Facility A to home. A blood test was obtained, and the results were received at 5:53 PM showing that Patient #1 had a blood alcohol level noted to be elevated at 207 mg/dL or 0.207% (the normal range is 0 - 10 mg/dL and level of legal intoxication in Texas is 0.08%) and a blood salicylate level of 21.1 (considered critical at > 30.0 mg/dL). A urine drug screen was obtained, and the results were received at 6:35 PM, showing that Patient #1 was also positive for benzodiazepines.

Patient #1 had abnormal results at 5:53 PM for the complete blood count (CBC) and comprehensive metabolic panel (CMP) that were collected at 5:10 PM as ordered by Staff #1, the treating ED physician. The abnormal results are as follows:
Red blood cells low at 3.98 M/uL (normal range is 4.20 - 5.40 M/uL)
Hemoglobin is low at 9.6 g/dL (normal range is 11.0 - 14.0 g/dL)
Blood urea nitrogen (BUN)was low at 6 mg/dL (normal range is 7 - 21 mg/dL)
Anion gap (AGap) high at 20.5 (normal range is 6.0 - 16.0)
Aspartate aminotransferase (AST/serum glutamic-oxaloacetic transaminase
(SGOT) is high at 69 U/L (normal range is 5 - 34 U/L)

Patient #1 was discharged home at 7:24 PM by the treating ED physician at Facility A, Staff #1, less than 3 hours from her presentation. Staff #1's "final diagnosis" was for alcohol intoxication without complication and misuse of over-the-counter medications. Patient #1's discharge instructions included a statement by Staff #1 that "emergent conditions may arise" and to return to the ED for "new, worsening, or any persistent conditions" at 7:12 PM. There is no documentation of the patient's psychiatric medical emergency.

Patient #1 was not provided a Suicide Risk Assessment or reassessments by the treating ED physicians at Facility A, nor did Patient #1 receive psychiatric/behavioral health medical screenings. The crisis clinician was not called in per policy for Patient #1, who presented to the emergency department due to a suicide attempt.

A review of the "Notification of Emergency Detention" form (completed by the attending
Sherriff's Office Staff #22) on 06/10/2019 at 6:33 PM and provided by Facility B:
" ...2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others
based upon the following:
Attempted to kill herself.
...4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to
me: (Patient #1) took an unknown, but up to 70 x 350 mg Aspirin. She told the responding deputy she took them to hurt herself.
5. The names, addresses, and relationship to the above-named person of those persons who reported or observed recent behavior, acts, attempts, statements, or threats of the
above-named person are (if applicable):
[Patient #1's] Boyfriend, live-in. For the above reasons, I present this notification
to seek temporary admission to the (name of facility) (Facility B) inpatient mental health facility or hospital facility for the detention of (name of person to be detained) (Patient #1) on an emergency basis ...."

Facility A did not provide nor possess a copy of a detention warrant for Patient #1, and the evidence shows that the detention warrant was obtained at Facility B.

A review of Patient #1's medical records at Facility B revealed she was discharged from Facility A on 06/10/2019 at 7:45 PM and was taken to Facility B by the police officer on 06/10/1029 at 8:26 PM for medical clearance before being admitted to a psychiatric unit. Patient #1 was emergently admitted at Facility B under observation at 12:20 AM with diagnoses that included: Aspirin poisoning with intended self-harm, intoxication, acute kidney injury, acute liver injury, alcohol intoxication with withdrawal symptoms, and sepsis.

A review of the document titled "Nursing notes" at Facility B on 06/10/2019 at 5:10 AM:
" ....The pt (Patient #1)was brought in by Parker County directly from Texas Health Azle. The officer reported that the hospital called them for transport, because the pt (Patient #1) tried to OD on Aspirin, and needed to be medically cleared before being sent to JPS for psych issues ..... The pt (Patient #1)'s clinicals/records were accessed through epic by the provider and the pt (Patient #1)'s labs from the hospital were not WNL (within normal limits). Pt (Patient #1) was sent to the ED for medical clearance from (Facility B) and was ultimately admitted to the hospital (at Facility B) for medical issues. Hospital house supervisor, psychiatric house supervisor, and provider were notified of this issue."

2. Patient #2:
The Medical Record Review at Hospital A for Patient #2 revealed the patient presented to the ED at 11:46 AM on 07/24/2019 with her mother due to anxiety, hallucinations, and inability to think clearly. Patient #2 was having auditory hallucinations, as evidenced by stating, "The birds mention that by saving the President, I plan to kill him," and multiple references to "the birds," as documented by the ED physician, Staff #16. No psychiatric screening exam was provided despite a recommendation by the facility's Licensed Medical Social Worker (Staff #19) for Patient #2 to be transferred for acute psychiatric hospital inpatient admission. Police took custody of Patient #2 after the patient signed out AMA inappropriately and never received a complete medical screening exam from a qualified physician. Hospital A's ED physician noted that "She signed out AMA from (Hospital A), then police were called to place her on a DW. Patient #2 was placed in observation while securing admission to inpatient psychiatric care.

A review of the Medical Record of the receiving facility, Hospital B: Patient #2, presented to the ED at 3:46 PM under a Detention Warrant (DW). Per the DW, Patient #2 stated she wanted to hurt herself and was having auditory hallucinations, again involving "the birds" speaking to her and Patient #2 wanting to kill the president. Hospital B completed a psychiatric medical screening exam at 5:40 PM.

Per a review of Facility A's policy titled, 'Suicide Risk Screening, Assessment, Precautions, and Management of Severe Non-Suicidal Self-Injurious Behavior', which was last reviewed by Facility A and became effective on 11/10/2022, was received on 05/01/2023 at 0633.

Facility A's process, which is outlined on page 1,
"2.0 Purpose:
2.1 To establish patient safety expectations for each Texas Health facility in the identification of patients who are at risk of Suicide.
2.2 To provide a validated screening tool to identify patient at risk for Suicide who require further assessment and steps to protect them from attempting Suicide.
2.3 To describe the process for screening for Suicide risk and developing a plan of care for patients screened as being at risk for harming self.
2.4 To provide guidelines for safety mitigation strategies for observing the patient and environmental modifications to address the needs for patients at risk for Suicide.
3.2 Patients identified as being a high risk for Suicide will receive an evidence-based Suicide Risk Assessment that directly asks about Suicidal Ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. Patients will be assessed by a Behavioral Health Crisis Clinician (BHCC) to determine appropriate plan of care, and/or be transferred to an appropriate behavioral health facility when medically stable."

Facility A's process is further outlined on page 3,
"4.1.2 Reassessment and changes in perceived Suicide Risk:
a. The Clinician should rescreen for risk of suicide and follow steps outlined in section 4.2. in the following situations:
2) anytime a patient makes an endorsement of suicidal ideation, self-harm ideations, and/or engages in any behaviors involving either Suicidal or Non-Suicidal Self-Directed Violence."

Facility A's process is further outlined on page 4,
"4.2 Suicidal Risk Screening Results
4.2.1 Patients admitted with a known or suspected Suicide Attempt should be treated as a high risk for Suicide.
b. 1) Patient presents due to an overdose and it is not clear whether it was an accidental overdose or an intentional act of Self-Directed Violence.
3) Patient presents intoxicated with a suspected Suicide Attempt and then later denies having Suicidal Ideation or attempting Suicide."

The staff members were asked if they had any policies regarding psychiatric/behavioral patient medical screenings and were also asked if they had any policy regarding the handling of psychiatric/behavioral patients.

Chief Operating Officer/Chief Nursing Officer (Staff #13) replied at 1:46 PM, "We're still looking through all the policies for the system. There are numerous BH policies." Based on a review of the policy provided, the policy was not followed as the suicide risk screening is required as a part of the MSE, and the suicide screening was not documented in the medical record review for Patient #1. This was confirmed during an interview with Facility A's Chief Operating Officer/Chief Nursing Officer (Staff #13).

An interview with the Emergency Department Director (Staff #15) on 4/28/23 at 1:35 PM revealed the ED physician (Staff #16) lacked core privileges for determining psychiatric medical instability. The ED physician (Staff #16) was the treating physician for Patient #2, who was experiencing an acute psychiatric emergency.

Based on a review of medical records, facility policy, and interview, the facility failed to provide an appropriate transfer and complete a memorandum of transfer (MOT) or provide medical treatment within its capacity that minimizes the risks to the individual's health for Patient #1 and Patient #2 who were experiencing a psychiatric emergency and were at high risk for self-harm and harm to others.

Findings included:

1. Patient #1:
A review of the medical record review at Facility A revealed that Patient #1 presented to Facility A's Emergency Department (ED) with Parker County Sherriff's Deputy (Other Staff #22) via EMS on a stretcher on 06/10/2019 at 1634 after being witnessed trying to hurt herself by taking "a handful" of aspirin. A blood test was obtained, and the results were received at 1753 on 06/10/2019 by the treating ED physician, Staff #1, showing that Patient #1 had a blood alcohol level noted to be elevated at 207 mg/dL (legal intoxication in Texas is 0.08% or 80 mg/dL and levels considered to be "normal" are 0 - 10 mg/dL) and a blood salicylate level of 21.1 mg/dL (normal levels = 0.0 - 30.0 mg/dL). A urine drug screen was obtained, and the results were received by Staff #1 1835 on 06/10/2019, showing that Patient #1 was also positive for benzodiazepines (negative is a normal finding). Patient #1 was "discharged home" at 1924 on 06/10/2019 by Staff #1, less than 3 hours from Patient #1's presentation to Facility A and following Staff #1's "final diagnosis" of alcohol intoxication without complication and misuse of over-the-counter medications, which implies medical instability.

A review of Facility B's medical record, the receiving hospital, for Patient #1 shows that Patient #1 arrived at the ED for Facility B in police custody (Parker County Sherriff's Department) on a Detention Warrant on 06/10/2019 2026. Patient #1's had abnormal vital signs as evidenced by a pulse rate of 136 bpm (normal is 60 - 100 bpm) and her blood salicylate level had risen to a level of 24.7 mg/dL (normal levels = 0.0 - 30.0 mg/dL) by 0615. Patient #1 was emergently admitted to Facility B under observation at 0020 with diagnoses that included: Aspirin poisoning with intended self-harm, intoxication, acute kidney injury, acute liver injury, alcohol intoxication with withdrawal symptoms, and sepsis.

These findings indicate that Patient #1 was not medically or psychiatrically stable when leaving Facility A as the patient required hospitalization and was not provided treatment within the hospital's capabilities to minimize risks. Facility A failed to follow its policy when Patient #1 was not transferred properly to the receiving hospital with an MOT and patient records.

2. Patient #2:
Patient #2 was allowed to sign out against medical advice (AMA) inappropriately while experiencing a psychiatric emergency. Facility A failed to complete MOTs with physician's certification on 07/24/2019 for Patient #2.

Patient #2 was transferred in police custody (after obtaining a Detention Warrant (DW) while having an acute psychiatric medical condition and without an agreement from a receiving facility to accept the transfer.

Patient #2 was transferred in police custody on 07/24/2019 without medical records from Facility A being sent to the receiving facility regarding their medical visit.

Patient #2 was discharged without the benefit of qualified personnel and transportation equipment. Additionally, the facility failed to provide medical treatment within its capacity to minimize the risks to individual health who were experiencing a psychiatric medical emergency.

No Memorandum of Transfer (MOT) could be located for Patient #2. There was no information about the risks and benefits of a transfer for Patient #2; there was no contact with another facility to obtain an agreement to accept the transfer for Patient #2; medical records were not sent to another facility for Patient #2.

Per the documentation review, Facility A's 'Direct Admit and Transfer Policy', last reviewed by Facility A and became effective on 02/20/2020, the policy stated on page 1, "Transfers and direct admissions of patients that require behavioral health services will be routed through the BHTC." The Direct Admit and Transfer Policy states on page 7, in part, "A psychiatric patient may be considered stable when he or she is protected and prevented from injuring or harming him/herself or others".

Per a review of Facility A's policy titled, 'Suicide Risk Screening, Assessment, Precautions, and Management of Severe Non-Suicidal Self-Injurious Behavior', which was last reviewed by Facility A and became effective on 11/10/2022, was received on 05/01/2023 at 0633. Facility A's process, which is outlined on page 1,
"2.0 Purpose:...
... 3.2 Patients identified as being a high risk for Suicide will receive an evidence-based Suicide Risk Assessment that directly asks about Suicidal Ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. Patients will be assessed by a Behavioral Health Crisis Clinician (BHCC) to determine appropriate plan of care, and/or be transferred to an appropriate behavioral health facility when medically stable."

An interview took place at 9:30 AM on 04/26/2023 with Facility A's Chief Operating Officer/Chief Nursing Officer (Staff #13), Facility A's Chief Quality Medical Officer (Staff #14), and Facility A's ED Director (Staff #15). The Staff members were asked why Patient #1 and Patient #2 were discharged without following Facility A's policies. Facility A's ED Director (Staff #15) stated that it was Facility A's understanding that patients who are in police custody and their practice was to always discharge the patient back into police custody. Facility A's ED Director (Staff #15) further stated Patient #2 came in under a DW (detention warrant). Facility A could not produce a DW when asked for a copy. The interview confirmed Facility A failed to follow its Direct Admit and Transfer policy.