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Based on staff interview, clinical record and administrative document review, the hospital failed to comply with the provisions of CFR 489.24 when Patient 1 did not receive stabilizing treatment within the hospital's capabilities. Patient 1 was diagnosed with a psychiatric emergency condition and the hospital did not fully implement the stabilizing measures as determined by the mental health crisis worker (CW 1). The stabilizing measures identified by CW 1 were located in Patient 1's home town and Patient 1 was discharged without a means to get to her home, a distance of 45 miles from the hospital. Subsequently, two days after the first visit Patient 1 was brought in by ambulance on a psychiatric 5150 hold for gravely disabled.

The failure to provide stabilizing measures within the capabilities of the hospital on the first visit resulted in preventable involuntary re-hospitalization and the potential of patient harm and injury.

Based on staff and patient interview, clinical and administrative document review, the hospital failed to provide stabilizing treatment within the hospital's capabilities when:

One of twenty patients (Patient 1) was diagnosed with a psychiatric emergency condition and the stabilizing measures determined by the mental health crisis worker 1(CW) were not fully implemented. The stabilizing measures identified by CW 1 were located in Patient 1 ' s home town and Patient 1 was discharged without a means to get to her home, a distance of 45 miles from the hospital. Subsequently, two days after the first visit Patient 1 was brought in by ambulance on a psychiatric 5150 hold (California Welfare and Institution 5150 code is an involuntary hold on the basis of danger to self, danger to others and/or gravely disabled) for gravely disabled. The failure to provide stabilizing measures within the capabilities of the hospital on the first visit resulted in preventable involuntary re-hospitalization and the potential of patient harm and injury.

Findings:

Review of the clinical record for Patient 1 indicated she was brought in by ambulance on 6/21/14 at 8:01 p.m. on a 5150 hold for danger to self (California Welfare and Institution 5150 code is an involuntary hold on the basis of danger to self, danger to others and/or gravely disabled). The emergency medical services (EMS) transport form stated the following: " ...talking very rapidly and easily distracted from questions. Per family on scene patient has been taking her medications irregularly and has been acting very erratically. Per SO (sheriff officer) patient was barricaded in her room when they entered the home and would not open the door. Family states patient seems to respond to internal stimuli (talking to trees and inanimate objects) and has been making suicidal statements..." The clinical record indicated Patient 1 was brought in from her home located approximately 45 miles from the hospital. The clinical record indicated the family was aware of the hospital Patient 1 was being taken to.

The nursing notes indicated registered nurse (RN 1) established the Emergency Severity Index (ESI - a method of establishing the severity of the presenting signs and symptoms) as 2 (urgent but not emergent) at 8:38 p.m. on 6/21/14. The suicide risk assessment was performed by RN 1 and noted ' yes ' to the items " ... (1) expressing suicidal thoughts without intent of imminent harm ... (2) evidence of psychiatric anxiety or turmoil ....and (3) recent significant loss and patient not coping well ... "

Medical Doctor (MD) 1 was the primary emergency physician who started his medical screen exam at 8:15 p.m. on 6/21/14 and noted the following: " ... 5150 acute behavioral emergency. Agitated here and declines much hx (history). Per paper work: ransacked house, was agitated and said she wanted to die ... " MD 1's assessment indicated the patient was depressed and suicidal. MD 1 indicated at 9:30 p.m. the patient was cleared medically (meaning Patient 1 did not have a medical reason for the psychiatric emergency) and ordered a psychiatric evaluation by the mental health crisis worker (CW). MD 1 signed out Patient 1 ' s care to MD 2 at 9:30 p.m. 6/21/14.

RN 1 nursing notes indicated CW 1 at bedside of Patient 1 at 11:11 p.m. CW 1 ' s hospital crisis evaluation form indicated the end of her evaluation was 1:13 a.m. on 6/22/14. The narrative at the bottom of the form stated " client was oriented 4X (meaning oriented to person, place, time and the reason for being in the hospital). Client denied homicidal/suicidal ideations/plans. Client was able to discuss reasons for living healthy ... Client agreed to safety plan and agreed to work with mental health services next week. Client was able to discuss and restate safety plan and agreed to it. Client was able to identify individuals of support ...if needed."

RN 1 note on 6/22/14 at 12:44 a.m. (late entry on 6/24/14 at 8:44 a.m.) indicated, "Pt. (patient) cleared by (CW 1). (CW 1) states that pt. is cooperative with discussing safety plan and will go see mental health this week. (CW 1) stated that she would be calling mental health to verify that the pt. has made contact with them."

RN 1 note on 6/22/14 at 12:45 a.m. stated "patient refused VS (vital signs) to be checked before discharge. Pt (patient) also refused to sign paperwork. Pt escorted out of ER by security. (Emergency Department Charge Nurse - EDCN) aware."

RN 1 note at 2 a.m. on 6/22/14 (late entry at 6/24/14 at 8:57 a.m.) indicated "... patient advised the doctor is discharging her to go home. I asked the patient if she had someone she could call to come and pick her up, patient stated that it was 1:30 in the morning , that nobody would come and pick her up. (EDCN) advised of the situation, a taxi voucher was being considered until it was noticed that the pt. lived in (a town 45 miles from the hospital)..."

MD 2 note on 6/22/14 at 2:38 a.m. indicated, "Patient was evaluated by the crisis worker and the 5150 was rescinded. Crisis worker states that a safety plan was discussed with the patient and that the patient is alert and oriented and capable of making an informed decision at this time. Patient agreed to the safety plan and is now ready for discharge..."

No clinical record documentation was provided to indicate the discharge to home order was modified to discharge to street. No clinical record was provided to indicate the ED physicians (MD 1 or MD 2), primary RN (RN 1) or charge RN spoke with the patient and asked whether or not she had resources in the local area near the hospital. No clinical record documentation was provided to indicate Patient 1 did not want family to be called.

Review of the clinical record for Patient 1 indicated she was brought in by ambulance on 6/24/14 at 6:32 a.m. on a 5150 hold for danger to self and gravely disabled. The EMS transport form stated the following: "Pt. (patient) was a missing person who had left (the hospital) after being discharged (from the hospital). Pt. was transported by EMS to (the hospital) per request of (local police department)."

MD 1 was the primary emergency physician who started the medical screen exam at 6:41 a.m. on 6/24/14 and noted: " ... was found this morning by a local business and was inappropriate in affect and authorities wrote 5150 ... " MD 1 signed out care to MD 3 at 7:00 a.m. 6/24/14.

RN 2 note on 6/24/14 at 7:25 a.m. indicated, "... Pt. (patient) with 7/10 medial back pain (pain in the middle of the back)..."

RN 2 note on 6/24/14 at 1:00 p.m., indicated, "pt (patient) started to have some visual hallucinations and stating that her bands (Hospital Identification Bands placed on wrist by hospital staff) are secretly monitoring her and allowing others to watch her. Pt. had D/C'd (discontinued) her own IV (intravenous line - tube in the vein) due to stating that it was 'bleeding' so she removed it. No bleeding observed to site. Pt's family at bedside at this time and keeps redirecting pt (patient) as needed..."

Crisis Worker 2 indicated on the Hospital Crisis Evaluation form on 6/24/14 at 3:45 p.m., "Pt.(patient) is oriented 4x (meaning oriented to person, place, time and the reason for being in the hospital). She is confused and tangential (with) loose associations. Her responses to questions are nonsensical. Per Pt. and family, she has no Hx (history) of (psychiatric) meds (medications) but does have a hx of taking meds. for a seizure disorder. Pt. denies SI/HI (suicidal ideations/homicidal ideations) and states no recollection of behaviors reported by her mother who she lives with. Family has arranged for placement at a SNF (skilled nursing facility) with hospice due to her terminal cancer..."

On 7/8/14 at 8:07 a.m., during an interview, MD 2 stated he took over the care of Patient 1 after hand-off from MD 1 at 9:30 p.m. on 6/21/14. MD 2 stated that the medical clearance of Patient 1 was completed by MD 1 and he understood the CW 1 had yet to evaluate the patient for the psychiatric emergency condition. MD 2 stated he did not receive report directly from CW 1 following the psychiatric evaluation and plan. MD 2 stated he read the written report by CW 1 and spoke to RN 1 prior to writing the discharge order. MD 2 acknowledged knowing Patient 1 lived approximately 45 miles from the hospital and that the taxi voucher was denied to send her home. MD 2 stated he did not realize the safety plan components identified by CW 1 were all located in Patient 1's home town (for example, safety plan, mental health clinic and support system and family members). When asked the role of the crisis worker, MD 2 confirmed the crisis worker evaluation was necessary to determine the stabilizing measures for psychiatric emergency condition. When asked if he would have changed the manner of his care if given the opportunity, MD 2 stated he would have taken report directly from CW 1 and would have insisted on the taxi voucher for Patient 1.

On 7/8/14 at 1:17 p.m., during an interview, MD 1 stated he was the primary emergency physician who performed the medical screen exam and cleared Patient 1 from having a medical component to the psychiatric emergency condition. MD 1 stated that he ordered the crisis worker evaluation for the psychiatric emergency condition. MD 1 confirmed that he signed the care over to MD 2 around 9:30 p.m. on 6/21/14. MD 1 stated the expectation of the evaluation by the mental health crisis worker was to establish and determine stabilizing measures for the psychiatric emergency condition.

On 7/8/14 at 2:12 p.m., during an interview, CW 1 confirmed she was called on 6/21/14 to conduct a psychiatric evaluation for Patient 1. CW 1 stated she interviewed Patient 1 for approximately two hours and established rapport and discussed the reason for the psychiatric evaluation. CW 1 stated she had determined Patient 1 was no longer a danger to self and lifted the 5150 hold because Patient 1 was able to agree and identify verbally to a safety plan. Patient 1 told CW 1 her aunt was her biggest support and she could depend on her to take her to the mental health clinic. Patient 1 ' s aunt lived in the same town as Patient 1. Patient 1 stated all she wanted to do was go home and get in her own bed and sleep. Patient 1 stated her reason for living included her daughters. CW 1 stated the following were the reasons she rescinded the 5150: 1. Patient 1 was able to verbalize a safety plan; 2. Patient 1 stated she would reach out to her aunt for support and her daughters as reasons for living; 3. Patient 1 stated she would go for walks in her neighborhood in response to stressors; 4. Patient 1 stated she would make an appointment with the mental health clinic in her city. CW 1 stated she knew all of the items of the safety plan constituted stabilizing measures and were located in the home town of Patient 1. CW 1 stated she discussed with RN 1 the rescinding of the 5150 hold and the plan to connect Patient 1 with the mental health clinic in Patient 1's home town the following week. CW 1 stated she did not speak directly to MD 2 or EDCN regarding the safety and discharge plan. CW 1 confirmed she did not speak to any ED staff regarding the specifics of the safety plan and that the measures in the safety plan were located in Patient 1 ' s home town. CW 1 stated she was not aware Patient 1 did not want her family called to come pick her up. CW 1 stated she was unaware Patient 1 would be discharged to the street. CW 1 stated she was aware Patient 1 lived in a city 45 miles from the hospital.

On 7/9/14 at 10:20 a.m., during an interview, RN 1 stated she was the primary nurse for the care of Patient 1 on 6/21/14. RN 1 stated Patient 1 was brought in by ambulance on a 5150 hold for danger to self. RN 1 stated that CW 1 came to see the patient for about two hours. RN 1 stated she was told by CW 1 that Patient 1 was cleared to go home and was to follow up with mental health clinic in Patient 1 ' s home town the following week. When asked whether the family was called, RN 1 stated she interpreted Patient 1 ' s comment regarding being 1:30 a.m. that she did not want her family called at all. RN 1 stated she offered Patient 1 to sleep in the ED and Patient 1 refused. RN 1 stated Patient 1 then became agitated, refused discharge vital signs, refused the discharge medications (oral potassium) and wanted to leave the hospital. RN 1 then stated Patient 1 was escorted by security out of the hospital. When asked why she did not call the family, RN 1 stated she did not want to violate Patient 1 ' s patient rights and breach confidentiality. When pointed out that the family had the information about the ED visit, RN 1 did not comment. When asked if Patient 1 had resources and family in the local area around the hospital, RN 1 stated she did not ask. When asked where Patient 1 was going after being discharged, RN 1 stated she did not know. When asked if Patient 1 had any money to get home, RN 1 stated she did not know. RN 1 stated that in retrospect she would have had better communication with CW 1 and she thinks they could have all worked better as a team.

On 7/9/14 at 10:01 a.m., during an interview, the EDCN stated she was aware of Patient 1 ' s psychiatric emergency condition and that CW 1 had conducted a psychiatric evaluation for the 6/21/14 ED visit. The EDCN stated CW 1 did not communicate with her directly about the results of the evaluation. EDCN stated she was given CW 1's plan to lift the 5150 hold and follow-up plan instructions from RN 1 and MD 2. The EDCN stated a taxi voucher was discussed for Patient 1, but because the patient lived 45 miles from the hospital and it would cost approximately $185, the taxi voucher was denied. EDCN stated RN 1 offered Patient 1 to sleep in a bed in the back hallway of the ED until morning, but she was told Patient 1 refused. The EDCN stated because the 5150 hold was lifted Patient 1 seemed able to make her own decisions and she did not want to violate Patient 1 ' s rights by calling her family. The EDCN stated she was not concerned about the patient being discharged to the street at 2 a.m. When asked whether or not Patient 1 had resources and/or family in the local area, the EDCN stated she did not know. When asked whether or not Patient 1 was asked where she was going and what she was going to do in local area, the EDCN did not know. When asked whether CW 1 discussed the stabilizing measures with her, she said ' no ' .

On 7/9/14 at 11:35 a.m., during an interview, the Chief Operations Officer (COO) stated, " We discharge patients to the street all the time. If they are adults, they can make their own decisions, we can ' t force them to stay or call their family if they don ' t want us to. We have homeless patients all the time, we can ' t keep them just because they are homeless, we have to discharge them to the street. " When the COO was reminded Patient 1 was not homeless and did not want her family called due to the time of night, there was no response.

On 7/10/14 at 10 a.m., in a group interview, MD 3 (Medical Director of the Emergency Department) and the Emergency Room Director (ED Dir) stated mental health crisis workers are called in on all 5150 psychiatric holds after a medical clearance. MD 3 and ED Dir explained the expectation is that the psychiatric evaluation conducted by the crisis worker was to be signed out to the primary physician and charge nurse and also the primary RN assigned to the patient. They stated the hospital has no policy and procedure that guides the crisis worker or the ED staff to make sure the evaluations and specific plan is communicated directly to the appropriate ED physician, charge nurse or primary RN. They stated the hospital has no surveillance or quality improvement project that collects data to measure whether communication of the crisis workers ' psychiatric evaluations are done according to expectations. Regarding the care of Patient 1 during the visit of 6/21/14, MD 3 and ED Dir stated and agreed CW 1 ' s psychiatric evaluation and stabilizing measures were not fully communicated directly to the primary ED physician or the charge nurse.

On 7/10/14 at 10:30 a.m., during an interview, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO), stated the hospital routinely denies taxi voucher requests for travel outside of the local area. The CNO and COO stated there was no policy or procedure guiding decisions regarding approvals or denials for taxi vouchers.

On 7/10/14 at 11:15 a.m. during a telephone interview with the patient, she was very reluctant to talk at first, but finally stated that she was brought into the hospital because of a seizure. She said her family knew she was there and the only reason she did not want them called to come get her was because it was 2:00 a.m. She stated several times during the interview that if it had been 10:00 p.m. and if her family was still awake, she would have let the hospital call them. She does not remember talking to the crisis worker. She stated there were so many people in and out of her room; she did not know who was who. She told the staff she did not have a car, any money, or a cell phone and they told her that was too bad and that she would just have to walk home. To her recollection she was never offered to sleep in a bed in the ED. She would not talk about where she spent the two days that she was missing; she just stated she was trying to walk home. Her speech was pressured and rapid during this interview. At times seemed confused, but was very clear about the time of night when this happened. She stated she just wanted to get home to her bed and her family and repeated several more times that she would have called her family if it had not been so late.

On 7/10/14 at 3:44 p.m. during an interview with the security guard, she stated: " When the nurse told patient (Patient 1) that she had been discharged and asked her if she had anybody that could come pick her up, the patient said, "It's late and there is nobody." Security guard stated Patient 1 said this with an attitude. According to the security guard, the Patient 1 did not want to leave the room she was in, but staff offered her another room in the department. This made Patient 1 angry and she then stated she just wanted to leave. She refused to allow staff to take her vitals, she ripped the O2 (oxygen) saturation monitor off her finger and threw it on the floor, and she refused to sign the paperwork and threw it on the floor also. She was also arguing with staff and demanding her pills. Security was asked by staff to walk out with her, but Patient 1 walked out on her own and was not "Escorted." The last time the security guard saw the patient, she was walking through the parking lot toward the street.

Review of the hospital Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure dated revised 1/2014 indicated on page 3 (of 15) under " ... 3. Stabilizing Treatment A. Stabilization of Emergency Medical Condition means: 1) providing such medical treatment of the condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during the transfer or discharge of the individual from a facility .... "

The local county 5150 response protocol (multi-agency agreement) of 2011 was reviewed and signed by the Chief Executive Officer of the hospital on 11/10/11 and indicated under " Introduction ...The purpose of the protocol is to provide for a coordinated response and shared understandings by all (local) county stakeholders of the roles, accountabilities and systems guiding the care of 5150 patients .... " ; on page 6 under " ...6. Upon arrival at (name of) Hospital: ... 2) the goal is to provide medical clearance and mental health evaluation within 60 minutes of arrival whenever possible; 3) Hospital staff will notify (name of) county Behavioral Health Crisis Response regarding need for a 5150 evaluation after medical clearance has been completed ... " ; under " ...Roles and Responsibilities: 1. Medical Clearance a. Medical evaluations of 5150 patients: 1) Individuals who are experiencing a psychiatric crisis and who are placed on a 5150 hold by law enforcement or other County-designated personnel are brought to the closest appropriate hospital ' s Emergency Department (ED) for assessment, treatment and stabilization of their physical conditions; 2) they are treated with the same medical evaluation, physical assessments, and triage principles as applied to any ED patient; 3) Until referred to another venue of treatment or discharged, each patient is under the primary care of the ED physician, unless otherwise noted ...c. Mental health evaluations of 5150 patients in the ED: 1) Upon completion of the medial clearance ED nurse will notify (local) County Behavioral health crisis staff of the need for a mental health evaluation; 2) (local) county Behavioral Health staff will respond in 60 minutes or less whenever possible ...d. Accounting for the 72-hour hold time: 1) in order to ensure that all available time is afforded the patient for an appropriate assessment, a comprehensive evaluation and stabilizing treatment, and ....2. Documentation /medical record: 1) documentation will be done per hospital policy ...Roles and Responsibilities: (local) County Department of Behavioral Health: 1. (local) County Department of Behavioral Health will complete 5150 evaluations applications. 2. Psychiatric evaluations and other services: 1) (local) County Behavioral health designated staff has the ability to complete mental health crisis assessments, 5150 applications, crisis interventions, and other emergency interventions for persons in (local) county as well as review, uphold and/or discontinue 5150 holds placed on individuals by other agencies ...5. Perform W & I (Welfare and Institutions) code 5150 evaluations: 1. Complete mental health crisis assessment: a) in the course of completing the 5150 assessment, the (local) county behavioral health staff will complete a mental health crisis evaluation; b) (local) county behavioral health staff will consult with law enforcement, Child Welfare Services, and hospital staff, as appropriate, to obtain additional information about a patient useful in the evaluation and subsequent treatment plan for the patient; c) a copy of the crisis evaluation form is provided to medical facility for inclusion in their medical record; ...6. Develop appropriate after-care plan for individuals who do not meet 5150 hold criteria: a)consult with individual/family members; b) refer to appropriate outpatient treatment services (e.g. of Behavioral Health Services, private insurance providers, other social services agencies as appropriate; c) consult with hospital staff; d) documentation of criteria determined and after care plan. 7 While at designated medical & correctional facilities: a) provide mental health information and training to facility staff regarding mental health concerns of the patient, as appropriate; b) provide input useful to hospital security staff in maintain and safe environment for all; c) There may be sharing of pertinent mental health and medical information between parties in order to best meet the needs of the patient ... "

No documented evidence or governing body minutes were provided to show the multi-agency document was incorporated in whole or in parts into hospital policy and procedures or other guidelines to help staff fulfill the intent of the multi-agency agreement.