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Based on policy review, medical record review, document review and interviews the hospital failed to ensure all patients presenting to the Emergency Department (ED) were provided an appropriate medical screening exam (MSE) within the hospital's capabilities for one (1) of 20 sampled patients, (Patient #1) in order to determine if an emergency medical condition (EMC) existed.

The findings included:

Patient #1 was a 26-year-old male who presented to Hospital #1 on 12/11/2021 at 4:21 PM with complaints of abdominal pain and reported he thought he had a tape worm because he could feel something moving in his stomach. Patient #1 had a history of suicidal ideations, mental health diagnoses and had sought treatment at Hospital #1 on three separate occasions (6/13/2021, 10/12/2021, and 10/13/2021) in 2021 for psychiatric concerns and/or suicide attempts. Patient #1 was triaged on 12/11/2021 at 4:45 PM, assigned an acuity level 3 with Moderate Risk of Suicide and seated in the fast track waiting area because there were no available ED rooms. There was no further assessment documented for Patient #1 and when he was called by a nurse on 12/11/2022 at 7:57 PM (over three hours later) he could not be located. The Hospital staff were unable to determine the time Patient #1 left the hospital premises. Patient #1's mother reported when her son refused to stay at the ED due to a long wait, she approached ED staff stationed at the ED entrance and pleaded with them to help Patient #1 because he had a history of suicide attempts. Patient #1's mother reported the ED representative stated there was no staff immediately available due to the volume of the ED. Patient #1 took his own life by severing his throat, with a knife, in his home on 12/13/2022, two days after leaving Hospital #1's ED.

Hospital #1 was found not to be in compliance with Federal Regulations found at 42 CFR 489.20 and CFR 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A2406

Based on policy review, medical record review, police report, death certificate and interviews the hospital failed to ensure all patients presenting to the Emergency Department (ED) were provided an appropriate medical screening exam (MSE) within the hospital's capabilities for one (1) of 20 sampled patients, (Patient #1), in order to determine if an emergency medical condition (EMC) existed.

The findings included:

1. Review of the hospital policy "Emergency Screening, Stabilization, and Transfer" approved February 2022 revealed, "Purpose: To establish procedures for the medical screening exam (MSE) of patients presenting to [named Hospital #1] requesting or requiring evaluation for determining if the patient has an emergency medical condition (EMC), and to provide appropriate stabilizing treatment. Policy: [named Hospital #1] provides MSEs within the capability of its emergency departments (ED) or Adult Psychiatric Assessment Service (PAS) in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), federal statute 42 CFR 489.24, mandate to determine whether an EMC exists, and (a) provide a medical examination and stabilizing treatment to individuals with an EMC, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth within this policy. Definitions: Emergency Medical Condition: The screening is conducted by a Qualified Medical Personnel (QMP) to determine whether the individual has an EMC, which is defined in 42 CFR 489.24 as: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: A. Placing the health of the individual or with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy. B. Serious impairment to bodily functions. C. Serious dysfunction of any bodily organ or part...State and federal regulations, including the EMTALA, federal statute 42 CFR 489.24, mandate that whenever an individual comes to the hospital's ED...when QMP present, requesting or requiring an examination or treatment, the individual shall receive a medical screening exam, to determine whether an EMC exists...Medical Screening Exams: An MSE is performed on all patients presenting to an ED...requesting or requiring an examination or treatment. The purpose of the MSE is to determine if the patient has an EMC. A If not brought to a treatment room immediately, patients are triaged to facilitate treatment and screening according to acuity and an MSE is performed as soon as possible...The MSE is a process that may require laboratory treating, diagnostic imaging, Consultation with specialists, or procedures to determine if and EMC is present..."

Review of the hospital "Suicide Risk Screening and Management in Non-Psychiatric Units" policy revealed, "Purpose:To outline the process by which patients in non-psychiatric areas aged 12 years and older are screened for suicide risk...Patients who screen positive for suicide risk are categorized according to the level of screened risk and appropriate interventions are implemented as follows: Elevated Risk (Yellow): The provider assesses the patient for safety and care recommendations. Mental health resources are provided to the patient and/or family prior to discharge. Moderate Risk (Orange): The provider assesses the patient for safety and care recommendations which may include a Behavioral Health Consult. Mental health resources are provided to the patient and/or family prior to discharge. High Risk (Red): The provider is immediately notified to determine plan of care which may include a Behavioral Health Consult and Suicide Precaution orders. Mental health resources are provided to the patient and/or family prior to discharge..."

Review of the "Emergency Department Triage" policy dated June 2020 revealed, "To define an organized and systematic method of assessing and prioritizing patient care...Acuity levels will be based on the ESI [Emergency Severity Index] categories I-V. Level I...defined as those patients that require immediate life saving interventions...Level II...defined as those patients in a high risk situation confused/lethargic/disoriented or in severe pain or distress...Level III...defined by acuity and predicted resource needs. The patient who requires two or more resources...Resources are defined as tests or procedures beyond the normal physician history and physical but not limited to labs, EKG [electrocardiogram], Radiology, IV [intravenous fluids]..."


2. Medical record review for Patient #1 revealed a 26 year old male who presented to Hospital #1's ED on 12/11/2021 at 4:21 PM via private vehicle with chief complaints of "abdominal pain" Triage was initiated at 4:45 PM with blood pressure recorded at 159/97. The triage nurse documented Patient #1 reported abdominal pain for 1 week during bowel movements but the abdominal pain had become constant. Patient #1 reported "I feel like I can feel something moving around, I think I may have a tape worm..." Patient #1 was assigned an acuity level 3 by the triage nurse. Labs were ordered at 4:23 PM-Complete Blood panel, Basic Metabolic panel, Hepatic function, and Lipase levels. The Columbia Suicide Rating Scale (CSSRS) was performed by the Triage Nurse at 4:51 PM. Patient #1 reported he had not wished to be dead in the past month, Patient #1 reported he had no suicidal thoughts in the past month, Patient #1 reported he had attempted suicide within the past 3 months to 1 year. Based on the responses Patient #1 was assigned a CSSRS of Orange or Moderate Risk. The Medical Screening Exam was initiated at 4:57 pm. At 4:59 PM, Patient #1 was seated in the fast track waiting room for lower acuity patients. At 7:57 PM, Patient #1 was called in the fast track waiting area, but could not be located. The lab orders were not completed due to Patient #1 leaving the hospital premises.

Patient #1 sought treatment at Hospital #1 for mental health care/suicide attempts 3 times in 2021, prior to the 12/11/2021 presentation.

On 6/13/2021- Patient #1 presented to the ED at 1:27 PM via Emergency Medical Services (EMS) after a suicide attempt. The MSE was initiated at 1:28 PM. Triage was initiated at 1:36 PM. The triage nurse documented, Patient #1 found by brother attempting to hang himself. Ingested 2 boxes of Benadryl, Risperdal and Lexapro in a suicide attempt last night. The CSSRS assessment revealed Patient #1 was a Red/High Risk and he was assigned an ESI 1. Labs, EKG, 1:1 Observation with suicide precautions were initiated. Patient #1 had a Computerized Tomography (CT) of the head and cervical spine, CT Angiogram of the neck, an inpatient consult for toxicology, and Versed medication was administered. Patient #1 was admitted to the medical Intensive Care Unit care at 5:16 PM. Patient #1 was hospitalized from 6/13/2021 through 6/17/2021 when he was discharged to the Psychiatric Hospital (on the same campus) after he was medically stable for psychiatric treatment.

On 10/12/2021- Patient #1 presented to the ED at 2:15 PM via private car with complaints of flu like symptoms. The MSE was initiated at 2:51 PM. At 3:05 PM, the ED provider documented Patient was dropped off at the ED by brother and mother for "psychiatric evaluation". Patient #1 stated he had not slept in 3 days and felt it had caused his schizophrenia to flare up. The provider convinced Patient #1 to go to a treatment room to get triaged. Triage was initiated at 3:23 PM and Patient #1 answered no to all questions on the CSSRS which scored as low risk, however Patient #1's mother reported Patient #1 had been acting abnormally and was found with a knife in his hand. The ED provider documented: Upon repeat assessment, patient stated that he did not hold a knife today with intent to commit suicide, however based on family reports and the patient history of suicide attempt, the provider placed Patient #1 on a 6404 (involuntary) hold at 3:06 PM with 1:1 monitoring. While in the ED labs were drawn with elevated glucose levels, elevated white blood cell count and positive for cannabis. A psychiatric consult was ordered and Patient #1 was admitted to the Psychiatric hospital (on the same campus) for further evaluation and management. Patient #1 care was transitioned to the Psychiatric hospital on 10/12/2021 at 5:47 PM and the patient was discharged from the ED at 6:15 PM.

On 10/13/2021 Patient #1 was transported to Hospital #1's ED from the Psychiatric Hospital via EMS for a self-inflicted wound to his neck from an ink pen. Patient #1 arrived in the ED at 8:28 AM with Triage documented upon arrival and assigned an ESI level 1, the MSE was initiated at 8:30 AM. Labs were ordered, an Angiogram of the neck was performed, a CT of the head and neck and chest Xray were performed. The results were a soft tissue injury to the neck with no evidence of vascular injury, no acute intracranial findings and no fracture or malalignment of the spine. The CT results were within normal limits. Patient #1 was medically cleared to return to the Psychiatric hospital and was discharged from the ED on 10/13/2021 at 11:22 AM.

3. The police (incident) report documented Patient #1 died on 12/13/2021 by a "weapon or cutting instrument" by "severe laceration to the throat area". The narrative documented Officers arrived and saw the victim laying in the bathroom floor unconscious and obvious extreme blood loss. The local Fire department arrived and provided medical treatment, however the victim was beyond help. The report documented a large butcher style knife approximately 6-8 inches long was laying on the desk in the living room and covered in blood. The report documented the complainant was the brother and the complainant reported he was laying in bed sleeping when he heard a loud thud in the bathroom, the complainant got up and found his brother (victim) laying in the bathroom beyond any help, attempted to control the bleeding and called 911, but the injury was too severe.

Review of the death certificate dated 12/13/2021 revealed Patient #1 died in his home on 12/13/2022 at 9:38 AM by "sharp force injuries of the neck" with the manner of death "suicide"

4. Review of documentation from Hospital #1's outpatient Behavioral Health Services revealed a physician progress note dated 1/1/2022, "...MD was informed by clinic RN that Pt's [patients] parents called the clinic to request help for themselves, and informed us that pt had completed suicide just over 2 weeks ago...On 12/11/21, pt brought himself to [named Hospital #1's ED] for evaluation of his abdomen. Pts father reports that this was strange as pt had never brought himself in for any form of medical evaluation. He [Patient #1] reportedly found out the ED wait time was 5.5 hours and left before being seen (only saw triage nurse)...On 12/13/21, pt completed suicide by using a knife to cut himself in the neck at home..."

5. In a telephone interview on 3/4/2022 at 8:05 AM, Patient #1's father verified Patient #1 sought care at Hospital #1's ED on 12/11/2021. The interview was conducted with Patient #1's father due to Patient #1's mother reporting she did not speak fluent English and wanted her husband to speak with the surveyor. Patient #1's father reported that his wife had to wait in the car on 12/11/2021 due to COVID restrictions at Hospital #1. Patient #1's father reported when Patient #1 refused to stay in Hospital #1's ED, due to the extended wait time, his wife went into the ED and spoke with a male inside the front reception area of the ED. Patient #1's father stated his wife told the ED staff her son had a high risk for suicide/previous attempts and he did not need to leave the ED. Patient #1's mother was reportedly told there was no staff available to assist Patient #1. Patient #1's father reported his wife did not have a name of the hospital representative she approached but reported "he was a white male- perhaps in his 60's"

In an interview on 3/9/2022 at 1:40 PM the Assistant Nurse Manager (ANM) for the ED assisted the surveyor with the electronic medical record review for Patient #1. The ANM for the ED was asked when Patient #1 left the ED on 12/11/2021. She stated based on the record review and "her best guess" it was 7:57 PM, Patient #1 was called in the waiting area and unable to be located. ANM for the ED verified RN #2 documented attempts to call Patient #1 on his cell phone at 12:05 AM on 12/12/2021 and 12:10 AM 12/12/2021. ANM for the ED further verified RN #2 followed hospital protocol (by calling the patient) for when a patient leaves without being seen by a provider. When asked why there was a delay on calling Patient #1 from 8:00 PM, when the patient was discovered to have left the ED until 12/12/2021 at 12:05 AM, ANM for the ED stated the delay in calling Patient #1 could have been due to the volume in the ED on 12/11/2021

In an interview, during the ED tour on 3/9/2022 at 9:38 AM, the ED Medical Director stated she recalled 12/11/2021 because it was the day of the Kentucky tornadoes and the ED received 17 critically ill patients from Kentucky and she had to bring in all available resources. A review of the metric provided by the ED Director revealed on 12/11/2021 at 4:21 PM [the time Patient #1 presented to the ED with complaints of abdominal pain]- The ED had 204 patients which placed the ED in a disaster category status, with the average wait for triage at 34 minutes and the average wait for an ED room as 2 hours and 23 minutes.

In an interview on 3/10/2022 at 9:30 AM, RN #1 verified she completed the triage for Patient #1 and he was placed in the fast track waiting room because there were no beds available in the ED due to surge capacity. RN #1 stated she was not sure when Patient #1 left the fast track waiting room.

In a zoom interview on 3/14/2022 at 9:00 AM, RN #2 stated her shift began at 6:45 PM on 12/11/2021. RN #2 verified she called Patient #1 on the telephone on 12/12/2021 at 12:05 AM and 12:10 AM as a follow up after he left the ED without being seen on 12/11/2021. RN #2 stated if a patient left with out being seen it was protocol to attempt to reach the patient by telephone to encourage then to return to the ED.

In a zoom interview on 3/10/2022 at 11:00 AM ED Physician #1 verified he was assigned the Triage area on 12/11/2021 when Patient #1 presented with abdominal pain. ED Physician #1 stated the physician assigned the triage area was the first provider contact, which initiated the medical screening exam. ED Physician #1 verified that he was physically present in the triage on 12/11/2021 and he observed, talked to Patient #1, and initiated lab orders. He stated he did not recall this patient exactly, but he had reviewed the medical record and noted he was a moderate risk for suicide based on his answers to the CSSRS. ED Physician #1 stated if he had identified any concerns for Patient #1, he would have initiated suicide precautions and/or sitter observations. ED Physician #1 stated based on his review of the chart the only complaint was of abdominal pain and he initiated protocols related to the chief complaint. ED Physician #1 stated what he did recall about 12/11/2021 were the tornadoes in Kentucky and stated it had been one of the busiest days he has ever worked in the ED with 30-35 level traumas in a 24 hour period. ED Physician #1 stated that contributed to the long wait time for the lower acuity patients on 12/11/2021.

The survey team was unable to identify the staff person that Patient #1's mother reportedly approached to voice concerns about Patient #1 leaving the ED on 12/11/2021. The survey team requested all staff working the registration area for 12/11/2022 and identified one male (RN #3) fitting the description "60 year old white male" as indicted by Patient #1's family. On 3/10/2022 at 9:12 AM, the surveyor interviewed RN #3, working as the as the COVID screener nurse who was stationed at the ED entrance on 12/11/2021. RN #3 stated he did not recall any family specifically approaching him to state a patient had left the ED and was suicidal.

There was no available ED video surveillance to review for 12/11/2021.