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Based on record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC), and failed to ensure that an EMC was stabilized prior to being discharged, for one patient (#14) of 23 Emergency Department (ED) records reviewed from 08/25/23 through 02/26/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatments and transfers of individuals with an EMC) Patient Transfer Policy," dated 02/28/23, showed the following:
- Any individual who presents to the ED shall be provided a MSE to determine whether the individual is experiencing an EMC.
- EMC means a medical condition manifesting itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances and/or symptoms of substance abuse (misuse of alcohol and/or other drugs), such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The MSE shall include those ancillary services routinely available to, although not located in, the ED.
- The ED physician on duty shall be responsible for the general care of all patients presenting themselves to the ED.
- Any individual experiencing an EMC must be stabilized prior to transfer or discharge.
- Stabilization is achieved when no medical deterioration is likely to result from transfer or discharge or the individual.
- An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided that the individual is given a plan for appropriate follow-up care as part of the discharge instructions.
- After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility.

Review of the hospital's undated policy titled, "Care of the Psychiatric Patient," showed the following:
- At-risk-behaviors demonstrated an imminent likelihood of serious harm to self or others as a result of suffering from a mental disorder.
- The ED physician may initiate a mental health consult with Facility F staff for appropriate discharge disposition.
- Once a consult with Facility F has been initiated, a mental health assessment will be conducted by their staff within 120 minutes of the initial request for psychiatric needs, including possible transfer.
- If inpatient therapy is indicated, the ED physician will order an appropriate transfer to an inpatient psychiatric unit once the patient has been determined to be medically stable.

Review of Patient #14's first medical record, dated 11/13/23, at 1:57 PM, showed he was a 48-year-old male who was transported to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), from police custody, for what was documented as being under the influence of a substance, seizure- (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) like activity and a psychotic (a serious mental illness characterized by defective or lost contact with reality) episode. Vital signs showed an elevated blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 177/99. Home medications included Depakote (a medication used to treat seizures and/or the manic phase of bipolar disorder, blood levels should be measured to determine whether or not they are in the usually accepted therapeutic range, 50-100 micrograms/milliliter) and medication for high blood pressure. No medication was administered, no testing or mental health evaluation was completed, and the patient did not participate in the physician's assessment. The BP was not reassessed. It was deemed the patient had a vasovagal (a sudden drop in HR and BP leading to fainting, often in reaction to a stressful trigger) episode and he was discharged back into police custody 41 minutes after his arrival.

Review of Patient #14's second medical record, dated 11/16/23, at 9:53 AM, showed he presented to the ED with a chief complaint of "needing to be checked out." He received a psychiatric evaluation with a recommendation for inpatient psychiatric treatment as he was a danger and could not make medical decisions. No placement was found, and the patient was discharged on 11/17/23, at 10:53 AM. Hospital staff walked him from the ED to an outpatient behavior health clinic appointment. During his 24 hour ED visit, no reassessments were documented by nursing staff other than a triage (process of determining the priority of a patient's treatment based on the severity of their condition) assessment. The last assessment documented for the patient was by the physician caring for the patient overnight in the ED when he signed over care to the oncoming physician on 11/17/23 at 7:00 AM. That assessment documented a continued plan for inpatient treatment. Blood work was obtained but did not include a Depakote level. A urine drug screen was positive for tetrahydrocannabinol (THC, synthetic marijuana, more harmful than plant-based marijuana) and benzodiazepines (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia). While medications were administered during this hospital stay, there was no documentation of their effectiveness with the improvement or decline of his psychiatric symptoms.

Review of Patient #14's third medical record, dated 11/18/23, at 10:42 PM, showed he presented to the ED with a chief complaint of needing a mental health evaluation and feeling overly excited. A Depakote level was ordered and found to be below the therapeutic range. A psychiatric evaluation was ordered with a recommendation for inpatient psychiatric treatment due to a grave disability with the presence of psychosis and erratic behavior. He was transferred to an inpatient psychiatric hospital on 11/19/23 at 2:57 PM, where he remained until his discharge on 11/27/23.

Please refer to 2406 and 2407 for further details.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) of 23 Emergency Department (ED) records reviewed from 08/25/23 through 02/26/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Patient Transfer Policy," dated 02/28/23, showed the following:
- Any individual who presents to the ED shall be provided a MSE to determine whether the individual is experiencing an EMC.
- EMC means a medical condition manifesting itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances and/or symptoms of substance abuse (misuse of alcohol and/or other drugs), such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The MSE shall include those ancillary services routinely available to, although not located in, the ED.
- The ED physician on duty shall be responsible for the general care of all patients presenting themselves to the ED.

Review of the hospital's undated policy titled, "Care of the Psychiatric Patient," showed at-risk-behaviors demonstrated an imminent likelihood of serious harm to self or others as a result of suffering from a mental disorder.

Although requested, the survey team did not receive police reports for Patient #14.

Review of the EMS document titled, "Excelsior Springs Fire Department, Patient Care Record," dated 11/13/23, showed that Patient #14's primary symptom and impression were behavioral psychiatric episode, with a chief complaint of psychiatric issues. Law enforcement dispatched Emergency Medical Services (EMS, emergency response personnel such as paramedics, first responders, etc.) to the law enforcement facility when Patient #14 was being fingerprinted and reported feeling dizzy. Officers assisted him to the ground to prevent him from falling and Patient #14 had seizure- (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) like activity. Upon the arrival of EMS, Patient #14 was lying on the floor, responsive to painful stimuli, but did not answer questions. Patient #14 was believed to be under the influence of an unknown substance. During EMS transport Patient #14 became alert and answered questions appropriately but refused to allow EMS to touch him and stated "you will regret this" if they did not let him go. EMS documented his mental status as combative throughout the transport. Upon their arrival the patient transferred himself to a bed and report was given to the ED Registered Nurse (RN). The patient's heart rate (HR, the number of times the heart beats within a certain time period, usually a minute) was 124, blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) was 182/115, and 170/107 when it was rechecked four minutes later.

Review of Patient #14's medical record dated 11/13/23, from Excelsior Springs Hospital, showed the following:
- He was a 48-year-old male who presented to the ED at 1:57 PM, by EMS and police, for a syncopal (to faint) episode.
- He had a past medical history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), high blood pressure, chronic pain in the right knee, strange and inexplicable behavior.
- Home medications included Depakote (a medication used to treat seizures and/or the manic phase of bipolar disorder, blood levels should be measured to determine whether or not they are in the usually accepted therapeutic range, 50-100 micrograms/milliliter) and Lisinopril (medication used to treat high blood pressure).
- Triage (process of determining the priority of a patient's treatment based on the severity of their condition) documentation showed Patient #14 arrived by private vehicle for a syncopal episode while in police custody. The patient did not verbally respond to the nurse but did allow for vital signs (body temperature [degree of hotness or coldness of the body, normal is 98.6 °F], BP, heart rate and breathing rate [RR]) to be checked. His temperature was 99.0, BP 177/99, RR of 17 and HR of 79.
- Physician documentation showed Patient #14 was very familiar to the ED and arrived via EMS in custody of law enforcement. EMS reported the patient was being fingerprinted when he had a syncopal episode. After that, the patient had what was reported as a "psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) event." After the psychotic event the patient was reported to be calm, alert and spoke. The patient was sent to the ED to determine if he was fit for jail. The patient elected not to participate in the interview or examination, laid on his back and was nonverbal. A review of symptoms was completed, the examination was inconsistent, but it was determined the patient was stable for confinement. The syncopal episode may or may not have been legitimate based on the patient's history as well as his current behavior.
- Patient #14 was discharged at 2:40 PM, (41 minutes after his arrival) with diagnosis that included syncope and collapse, bipolar disorder, malingerer (to fake psychological or physical symptoms for secondary gains), imprisonment and other incarceration. Vital signs at discharge were identical to triage vital signs. Instructions for after discharge included information on vasovagal (a sudden drop in HR and BP leading to fainting, often in reaction to a stressful trigger) reaction and to follow up with his primary care provider in five to seven days. No testing or mental health evaluation was completed during the ED visit.

Patient #14's medical records showed he returned to the ED on 11/16/23, his second ED visit, for psychiatric issues. He had a psychiatric evaluation with a recommendation of inpatient psychiatric treatment as he was a danger and could not make medical decisions. After 20 hours of attempting to find inpatient placement, no placement was found; and he was discharged on 11/17/23 at 10:53 AM. ED staff walked him to an outpatient behavioral health clinic for assessment and treatment. No Depakote level was obtained during the 11/16/23 ED visit. He returned to the ED the next day on 11/18/23, received a psychiatric evaluation with recommendations again for inpatient treatment. A Depakote level was obtained and showed lower than therapeutic levels. He was transferred to an inpatient psychiatric facility where he received medications and treatment until 11/27/23.

During an interview on 02/28/24 at 10:00 AM, Staff E, ED Medical Director, stated that he treated Patient #14 in the ED for his 11/13/23 and 11/16/23 visits. On 11/13/23 he did not order any testing because Patient #14 most likely just wanted to avoid police custody or arrest. It was a vasovagal response to being fingerprinted. The 11/16/23 visit included a psychiatric evaluation with a recommended inpatient placement. The psychiatric evaluation was just a recommendation and not a rule.

During an interview on 03/06/24 at 6:45 AM, Staff L, Police Officer, stated that he was the officer who responded to multiple calls around 11/13/23 with regard to Patient #14. He believed that the incident on 11/13/23 was due to Patient #14's erratic behavior of attempting to remove the roof of a neighbor's home and police were called for the third time in 24 hours. Officers arrested him for trespassing and while Patient #14 was being fingerprinted, the patient "passed out." During the time the patient was on the ground, he would not speak but peeked at officers. Staff L could not decide if the patient was genuinely having a medical issue or if he was just trying to get out of being arrested, as he kept peeking at them. EMS was called to the jail and the patient was transferred to the hospital. He hoped Patient #14 received placement so his wife could get an order of protection. After Patient #14 was released from the hospital, police were called to the local high school because Patient #14 was trespassing. He was not in a healthy mindset and not completely coherent. Some offenders did try to play ill to get out of being arrested, but Patient #14's behaviors were definitely real.

Although requested, no interviews were conducted with EMS personnel.

Based on interview, record review and policy review, the hospital failed to follow its policies and ensure an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) was stabilized when one patient (#14) of 23 sampled cases from 08/25/23 through 02/26/24, was discharged with an unstable medical condition.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatments and transfers of individuals with an EMC) Patient Transfer Policy," dated 02/28/23, showed the following:
- Any individual who presents to the Emergency Department (ED) shall be provided a medical screening examination (MSE) to determine whether the individual is experiencing an EMC.
- EMC means a medical condition manifesting itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances and/or symptoms of substance abuse (misuse of alcohol and/or other drugs), such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The MSE shall include those ancillary services routinely available to, although not located in, the ED.
- The ED physician on duty shall be responsible for the general care of all patients presenting themselves to the ED.
- Any individual experiencing an EMC must be stabilized prior to transfer or discharge.
- Stabilization is achieved when no medical deterioration is likely to result from transfer or discharge or the individual.
- An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided that the individual is given a plan for appropriate follow-up care as part of the discharge instructions.
- After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility.

Review of the hospital's undated policy titled, "Care of the Psychiatric Patient," showed the following:
- At-risk-behaviors demonstrated an imminent likelihood of serious harm to self or others as a result of suffering from a mental disorder.
- The ED physician may initiate a mental health consult with Facility F staff for appropriate discharge disposition.
- Once a consult with Facility F has been initiated, a mental health assessment will be conducted by their staff within 120 minutes of the initial request for psychiatric needs, including possible transfer.
- If inpatient therapy is indicated, the ED physician will order an appropriate transfer to an inpatient psychiatric unit once the patient has been determined to be medically stable.

Although requested, the survey team did not receive police reports for Patient #14.

Review of Patient #14's medical record dated 11/16/23, from Excelsior Springs Hospital, showed the following:
- He presented to the ED at 9:53 AM, with a chief complaint of "needing to be checked out."
- Nurse triage (process of determining the priority of a patient's treatment based on the severity of their condition) documentation at 9:53 AM, showed a chief complaint of the patient requesting to be checked out. Vital signs were obtained, and the patient was given an acuity (the severity of a patient's illness and the level of service needed) level of four. The patient's wife reported she was concerned for her safety. Patient #14 had not been acting right, attempted to rip the roof from their home and threw out things from their home. Patient #14 stated the holy spirit dwelled inside of him.
- History of present illness showed that Patient #14 presented and reported noncompliance with psychiatric medications and psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) episodes. Patient #14's wife reported to the physician that he had flushed all his medications down the toilet, ripped the roof off their home and acted erratically. Recently he went to a local business, went into the staff breakroom and watched television because he was directed to do so by the holy spirit. The patient did not believe his wife was really his wife but an imposter and the devil. He denied homicidal ideation (HI, thoughts or attempts to cause another's death) and suicidal/suicidal ideation (SI, thoughts of causing one's own death). Patient #14's wife told the physician that she did not feel safe in their home, and the patient had called police to remove her from their home because he felt she was an imposter.
- Vital signs showed a BP of 161/97. He was administered Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) and Geodon (an antipsychotic medication used to treat schizophrenia [serious mental disorder that affects a person's ability to think, feel and behave clearly] and the manic symptoms of bipolar disorder [manic depression]), lab work was ordered and included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), urine drug screen, comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), acetaminophen (pain medication, also used to reduce fever), salicylate and alcohol level, and a psychiatric consultation was requested.
- A psychiatric consult was completed at 10:43 AM, and the overall impression was that Patient #14 had been off his psychiatric medications for two weeks. The patient had ripped furniture from the home, had auditory hallucinations (hearing things that are not heard by others, imaginary), was hyper-religious (a psychiatric disturbance in which a person experiences intense religious beliefs or episodes that interfere with normal functioning) and baptized himself multiple times a day at home. Patient #14 was a danger to himself and others, was gravely disabled and met criteria for admission to an inpatient psychiatric hospital. He was diagnosed with bipolar disorder, manic (elevated or excited mood or behavior) with psychotic features and did not have the capacity to make healthcare decisions as he was not capable of understanding the nature of his illness.
- Physician documentation on 11/17/23 at 7:05 AM, showed nursing staff had made several attempts at placing the patient in an inpatient psychiatric hospital, but at the shift change he had still not been accepted. There were no significant overnight events, but Patient #14 had not slept. He watched TV and drank coffee. The patient went to the bathroom several times, which was initially believed due to all the coffee he drank, but later it was found that the patient had collected multiple paper towels and had written on them. Care was transitioned to the day shift physician with a continued plan for inpatient placement. There was no documentation of a physician assessment after 11/17/23 at 7:05 AM.
- Nursing documentation on 11/17/23 at 9:15 AM, showed that four inpatient psychiatric hospitals had been contacted and none had available beds. The physician was updated.
- At 9:36 AM, nursing documentation showed Patient #14's daughter was contacted as they were not able to contact the patient's wife. The nurse left a message for the daughter to call her back to discuss the patient's plan of care.
- At 10:00 AM, nursing documentation showed one of the patient's daughters called the nurse and reported that the patient had contacted her and reported he was going home. The daughter was updated with the plan to discharge the patient. A representative from Facility B was contacted and an outpatient appointment was made for Patient #14 at 11:00 AM.
- Patient #14 was discharged from the hospital at 10:53 AM, with his family and an appointment for outpatient treatment at Facility B at 11:00 AM. Medications administered during his ED visit included Ativan, Geodon and risperidone (a medication used to manage certain mental/mood disorders).

Review of Patient #14's medical record on 11/17/23, from Facility B, showed the following:
- He met with a counselor at 11:13 AM, was cooperative and attentive and had no thoughts of self-harm or harming others. The patient agreed to therapy for crisis intervention but denied a need for future therapy sessions. Patient #14 reported that Excelsior Springs Hospital sent him to the appointment because he had not been taking his medications, which led him to become overly excited and frightened by his family. He reported he stopped his medications because he feared they had fentanyl (a medication used to treat severe pain and is a high risk drug for theft and personal use) in them. He agreed to try medication again as it was beneficial to him. He denied a need for therapy.
- Physician documentation showed that Patient #14 presented to the crisis walk-in clinic from the Excelsior Springs ED. The patient had been seen there overnight and attempts without success of finding him an inpatient bed for greater than 20 hours. The patient called his daughter/family stating he was ready to be discharged. Based on the patient not being an imminent threat to himself or others, the ED physician was able to convince him to be seen, assessed and further evaluated at a crisis appointment before he was discharged home.
- A psychiatric review of symptoms showed Patient #14 minimized some of the recent concerns, including the reason for police taking him to the ED on 11/16/23 which was erratic/inappropriate behavior including trespassing at the local business' staff area, compulsive behavior including writing profusely on toilet paper, pacing restlessly, reciting passages from the bible, and had not slept for days. He did rest in the ED after being given medications. Patient #14 had a history of impulsivity related to decompensation, disinhibited erratic behavior like trespassing, and random acts of religious excess. Multiple phone calls were made from his residence to the police, who reportedly were well-informed and very aware of the patient and his history when nonadherent to medications.
- Final diagnosis included bipolar disorder, current episode manic without psychotic features, chronic mental illness, referential thoughts and nonadherence to medications.

Review of Patient #14's medical record dated 11/18/23, from Excelsior Springs Hospital, showed the following:
- He presented to the ED at 10:42 PM, from Facility C, without police escort, with a chief complaint of needing a mental health evaluation and feeling overly excited.
- A history of present illness showed Patient #14 denied SI, HI, hallucinations, pain, discomfort, injury or trauma. On 11/16/23 he presented to the ED for a mental health evaluation for psychosis and mania. Placement was not able to be obtained, so outpatient arrangements were made. He was seen in the behavioral health clinic on 11/17/23 with similar issues. The physician contacted Patient #14's wife and she reported that he had been acting bizarrely and inappropriately for at least three weeks. He tried to join a local parade attempting to impersonate Santa Claus and earlier in the day presented to a local hotel and trespassed into someone's wedding. He broke into the back room/storage area of their children's school and local police had been called to their home 16 or 17 times in the last few days. The patient was calm and cooperative during the evaluation, alert and oriented to person, place time and situation. The patient was given Depakote and blood pressure medication and a psychiatric evaluation was ordered. Laboratory work was ordered and included a CBC, CMP, Depakote level, acetaminophen level, salicylate level, alcohol level, urine drug screen and urinalysis. His Depakote level result was low at less than 10 (normal therapeutic range is 50 to 100).
- A psychiatric evaluation recommended inpatient placement due to grave disability with the presence of psychosis, erratic behavior and failure to improve with outpatient care.
- Patient #14 was transferred to an inpatient psychiatric hospital on 11/19/23 at 2:57 PM.

Review of Patient #14's medical record from Facility E, dated 11/19/23 through 11/27/23, showed Patient #14 was transferred for psychosis and erratic behaviors that required intervention from law enforcement numerous times within the last few days. Patient #14 was evaluated by the Excelsior Springs Hospital ED on 11/16/23, after presenting there for religious themed delusional thoughts claiming that he was Jesus Christ and making references of "my father living inside me." Inpatient psychiatric admission was recommended at that time; however, the patient was discharged due to lack of available beds and outpatient treatment arrangements were made. The patient had a history of non-compliance with his prescribed medications and a history of methamphetamine use. His urine drug screen was positive for Tetrahydrocannabinol (THC) is the principal psychoactive constituent of cannabis and one of at least 113 total cannabinoids identified on the plant. Oral medications were started, along with therapy and he was discharged on 11/27/23 to his home.

During an interview on 02/28/24 at 10:00 AM, Staff E, ED Medical Director, stated that he treated Patient #14 in the ED on 11/16/23. The 11/16/23 visit included a psychiatric evaluation with a recommended inpatient placement. The psychiatric evaluation was just a recommendation and not a rule. An assessment of the patient when he resumed care on 11/17/23 should have been completed, but he did not remember if he did an assessment and there was no documentation of one. Patient #14 had been given medication during his ED visit and had improved enough by the time he resumed care that he felt the patient was stable enough to discharge to an outpatient setting. ED staff walked him to the outpatient appointment and he was seen. Depakote was not given due to the patient's improvement overnight with other medications. Patient #14 had never been anything but polite and never harmed anyone. The patient often read the bible and then believed he no longer needed his medications, would get hyper-biblical and out of hand. If a patient ever became nonfunctional or a threat, he would never discharge them to outpatient treatment. He felt Patient #14 had improved so much that staying in the ED waiting for inpatient placement would have been more harmful that discharging him to be treated as an outpatient. If the physician working in the behavioral health clinic thought there were issues with Patient #14, he would have sent him back to the ED. Patient #14 was not discharged because there were no inpatient beds. He wished there had been another evaluation of Patient #14 documented on 11/17/23 that showed how much he had improved. He couldn't remember if he had treated him since the visit on 11/16/23.

During an interview on 02/28/24 at 8:15 AM, Staff K, ED Physician, stated that he was the night shift physician who cared for Patient #14 on 11/16/23 through 7:00 AM on 11/17/23 when he passed care off to Staff E. Patient #14 was not a typical psychiatric patient, he was extremely polite and friendly. Patient #14 had not slept overnight and used the restroom a lot. It turned out he was writing on paper towels. He was not remarkedly better at the end of his shift and basically the same as when his shift began. He had seen Patient #14 in the ED on several occasions after his visit on 11/16/23, and all were visits related to psychiatric issues.

Although requested, no interviews were conducted with EMS personnel.