HospitalInspections.org

Based on a review of five open and 18 closed medical records, it was determined that one patient (P22) who was seen in the ED in June 2019, did not have a MSE sufficient to determine if P22 had an emergency medical condition.

P22 was a 50+ year old patient with a history of a psychiatric disorder who presented to the Emergency Department (ED) with thoughts self-harm and a stated plan. The ED physician determined that the patient needed to be moved to the Behavioral Health Unit (BHU), placed on 1:1 observation and was to have a psychiatric evaluation. Patient was given with the Columbia Suicide Severity Rating Scale and found to be at a high risk for self-harm.

Over the next 12 hours, two nursing notes were found that stated "patient needs to be evaluated by behavioral health." One nursing note listed the following questions and answers:

1. Have you ever attempted suicide? "yes"
2. When was the last time? "today"
3. How was this attempted? "overdose"

P22 told the nurse and the ED physician that he/she had attempted to overdose on alcohol and drugs. No documentation was found to confirm that P22 was evaluated by a behavioral health provider at any time while in the ED.

One ED physician note written near the time of discharge stated "Patient no longer endorsing self-harm, stated this was in the context of being high." The alcohol testing ordered for P22 came back negative. However, no results were found for a urine drug test that had been ordered by the physician to confirm what, if any, drugs the patient may have been taking.

The patient was discharged home less than 24 hours after presenting to the ED and per the nursing note "given food, bus tokens and clothing and sent out ambulatory".