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Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to ensure an appropriate medical screening exam was provided for patients who presented to the hospital's DED for a psychiatric evaluation (Patient #5 and #7); failed to provide stabilizing treatment for patients who presented to the hospital's DED for psychiatric evaluation (Patient #5 and #7).

The Findings include:

Based on policy reviews, closed medical record reviews, staff and physician interviews the hospital's dedicated emergency department (DED) failed to ensure an appropriate medical screening exam was performed for 2 of 11 sampled DED patients that presented with an psychiatric emergency medical condition (Patient #5 and #7)

~cross refer to Medical Screening Exam, Tag A2406.

Based on policy reviews, closed medical record reviews, staff and physician interviews the hospital's DED failed to provide stabilizing treatment for 2 of 11 sampled DED patients (Patient #5 and #7) who presented to the hospital's DED for psychiatric evaluation.

~cross refer to Stabilizing Treatment, Tag A2407.

Based on policy reviews, closed medical record reviews, staff and physician interviews the hospital's dedicated emergency department (DED) failed to ensure an appropriate medical screening exam was performed for 2 of 11 sampled DED patients that presented with an psychiatric emergency medical condition (Patient #5 and #7).

The findings included:

Review of the policy and procedure titled "EMTALA" reviewed 02/2020 revealed "Policy It is the policy of (Named) Health Care ("Hospital) that any individual who comes to the Hospital requesting examination or treatment for a medical condition is entitled to and will receive a Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) ...In compliance with EMTALA's objectives and requirements, it is the Hospital's express policy that, where an individual, regardless of his or her ability to pay, comes to the Hospital requesting examination or treatment for a medical condition, the Hospital, within its Capabilities will provide:-An appropriate Medical Screening Examination by a Qualified Medical Person ..."

1. Closed medical record review on 05/12/2021 revealed Patient #5 was a 12-year-old female who presented to the DED on 02/28/2021 at 1845 with complaints of lethargic, hot flashes, and dizzy. Review revealed a MSE started at 1846. Review of a Psychiatric Assessment dated 02/28/2021 at 1900 revealed "pt states has been feeling like hurting herself and show RN (registered nurse) healed/old self injury marks on left forarm, (sic) states she can't talk to her dad because she is afraid he will be disappointed in her...states family doesn't (sic) have extra money for counselors d/t (due to) mother is the only one working. Reports feels like if she was a boy she would be more confident. Suicide Attempt or Gesture Self-Injury..." Review of the Columbia Suicide Assessment dated 02/28/2021 at 1900 revealed "Q1. Wish to be dead Yes- in past month; Q2. Current suicidal thoughts Yes- in past month; Q3. Suicidal thoughts /c Method (no specific plan or intent) Not in past month; Q4. Suicidal Intent without Specific Plan Yes- in past month; Q5. Intent with Specific Plan Not in past month ...Q6. Suicidal Behavior in Past No; Risk Factors: Presenting Symptoms Anhedonia, Hopelessness/Despair, Anxiety and/or Panic; Precipitants/Stressors Inadequate Social Supports, Perceived Burden on Othrs; (sic) ...Columbia Suicide Severity Score 52; Columbia Suicidal Screen Risk Degree High Risk; Provider Notification: Provider Notified (named MD #2)." Review of MD #2's Provider Note dated 02/28/2021 at 2323 revealed "Chief Complaint: Psychiatric Stated Complaint: LETHARGIC/HOT FLASHES/DIZZY...Source: patient...History of Present Illness Presenting Illness: Description Patient presents the department (sic) with multiple complaints. She has been having dizziness episodes when she stands up as well as episodes where she feels a tingling sensation in her hands further goes on to complain of a nightmare type sensation that has been ongoing for the past several months which she has not been sleeping well...The patient did state that approximately 1 year ago, she was having suicidal thoughts and she had worked as a (sic) school counselor at that time and has been cleared of those thoughts since then has not been talking with a counselor recently...When the patient was interviewed outside of the dad, she does explain that she has been rather depressed recently and she has been cutting herself. She says that she has not been feeling suicidal recently however she has had these thoughts in the past. She has not told her parents that she has been cutting herself...She also is worried about disappointing her parents. She is unhappy with her looks and that she has been taking some of her mom ' s make-up. Today, her dad had found out about that and she had gotten in trouble for that today. She also is worried about disappointing her parents especially with her grades, apparently she is not doing well into (sic) classes. Review of systems...Psychiatric: Positive for: depression, stress; Negative for: suicidal ideation...Medical Decision Making Patient presents the department (sic) several concerns including feeling a dizzy (sic) and lightheaded as well as some depressive issues. When speaking away from the dad, the patient does complain of depressive issues as well as self-harm behavior. She is concerned about some issues with her appearance as well and feels like if she was a boy should be strong questioning some sexual identity issues. The patient does not want her parents know about this at this time. I did discuss with her about this including possibly using the school counselor now that she is back in school for assistance with this. She is in agreement with this. The patient was also further encouraged to discuss this more with her primary care provider. This point, (sic) the patient denied suicidal ideations does have forward thinking therefore she would not be required to stay in the emergency department overnight. She be (sic) discharged home with dad with primary care follow-up as an outpatient. She feels comfortable with this plan...Patient Instructions: (Named) Behavioral Health Discharge Resources, Near Syncope (ED). Referrals: (Named) PCP 2 to 4 Days..." Review of the Patient Visit Information signed (unable to make out signature) at 2125 revealed "You were seen today for: Dizziness...Follow-up Please contact the following to make an appointment for follow-up care: (Named PCP)..." Patient #1 was discharged home with her dad at 2129. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #5 on 2/28/2021, as evidenced by failing to ensure that Patient #5 was evaluated by Behavioral Health.

Interview on 05/12/2021 at 1131 with MD #2 revealed Patient #5 did not present with any "acute concerns" such as suicidal ideations. Interview revealed Patient #1 did report self-cutting but nothing "acute." Interview revealed Patient #5 had seen her school counselor in the past which helped, and her PCP offered mental health services. MD #2 stated he had conversations with Patient #5's dad and he was on board with discharging and utilizing the school counselor and PCP. Interview revealed MD #2 usually offered the parents a psychiatric consult with minors, however he did not recall if he offered a psychiatric consult to Patient #5's father. Interview revealed if Patient #5 had reported active suicidal ideations, he would have held her in the DED overnight until a psychiatric consult was completed. Interview revealed MD #2 inquired several times to Patient #5 if she had suicidal thoughts, which she reported in the past but not currently.


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2. Closed medical record review on 05/12/2021 revealed Patient #7 (1st visit) was a 57-year-old female who presented to DED on 04/08/2021 at 0756. Review revealed at 0804 Triage Assessment "Pt brought to ED by EMS (emergency medical services). EMS reports that they were called for c/o (complaint of) vaginal bugs. Pt told EMS she has removed 14 bugs from her vagina that look like raviolie [sic]. On arrival pt reports she has had a man that has been threatening to kill her over money that her brother owes him for drugs. She took her cats and hid in the woods last nights to keep her cats safe. 'I'm ok with dying but I need protection for my cats and the sherriff [sic] wouldn't protect them.' Pt states 'There are many bugs out there and now I have them falling out of my vagina. I had 14 plops, loud plops fall out and they look like clear raviolie [sic]. Please get the rest out of me.' Pt reports last drank 2 nights ago. Last used meth a couple of days ago and cocaine last night." Review revealed MSE began at 0904. Review of "ED Provider Note" at 0904 revealed "Chief Complaint: Psychiatric; Stated Complaint: Bugs in Vagina; Presenting Illness Description: Patient is a 57-year -old female with a stated past medical history of PTSD (post-traumatic stress disorder), methamphetamine/cocaine/ ETOH (alcohol) abuse who presents via EMS with complaints of 'bugs are coming out of my vagina.' Patients states that this has been occurring 'all morning since she was in the woods last night. Patient is oriented but difficult to redirect. Patient states last methamphetamine used was last night. Patient describes vaginal discharge that is 'clear like ravioli's' that is remained stable since onset and denies any relieving factors. Patient denies any headaches, vision changes, tinnitus, sore throat, productive cough, shortness of breath... Physical Exam: Pelvic: External female genitalia without abnormalities, lesions, or rashes. Speculum exam shows no evidence of any parasites or abnormal discharge/blood in the vaginal vault....Medical Decision Making: Patient is a 57-year-old female who presents via EMS for vaginal parasitosis. Pelvic exam does not show any evidence of acute abnormalities internally or externally that would explain the sensation. Patient also upon discussion of discharge states that she has 'bugs in my ass'. Patient was given the opportunity to provide stool sample here in the emergency department...Patient denies any suicidal ideation, homicidal ideation, auditory/visual hallucinations. The patient has been reexamined and ready to be discharged..." Review of "Nursing Notes" at 0916 revealed "Pt very anxious and crying out that the bugs are all over her. Staff attempted to calm pt and gave the pt some body cleansing wiped to clean herself. Pt very concerned about her cats." Review of "Nursing Notes" at 1055 revealed "Pt sitting in chair in room. Nurse explained that she needed to get dressed and I will review the d/c (discharge) paperwork with her so she can go home." Review of "Nursing Notes" at 1118 revealed "Pt still sitting in chair, cleaning herself with cleansing wipes before getting dressed." Review revealed the patient was discharged at 1125 with instructions for Behavior Health Resources. Review of medical record revealed no psychiatric consult was ordered or conducted.

Closed medical record revealed Patient #7 (2nd visit) returned to facility's DED on 04/08/2021 at 1325 (2 hours after discharge) via LEO (law enforcement officer) under IVC (involuntary commitment petition). Review revealed Patient #7 was escorted out of the hospital by security at discharge during her first encounter and she entered traffic around the hospital. Review of the IVC revealed "Patient was seen in this ED earlier in the day with a chief complaint of bugs everywhere inside of her and she busted a knuckle on her suitcase trying to get rid of the bugs...She presents to the ED under an IVC currently for these hallucinations and delusions secondary to meth use. Patient has no known psychiatric history...." Review revealed MSE began at 1342. Review revealed Psychiatric Consult was ordered and performed at 1426. Review revealed "Psychiatric Consult: Provisional Diagnosis: Substance - Induced Psychotic disorder; Impression Plan: Patient is recommended for IP psychiatric care due to exacerbated psychotic disorder with delusions secondary to methamphetamine use. IVC in place for safety." Review revealed Patient #7 was transferred to an inpatient psychiatric facility on 04/09/2021 at 0843.

Interview on 05/12/2021 at 1203 with MD #3 revealed he was the attending who performed MSE for Patient #7 in both visits. Interview revealed Patient #7 denied suicidal/ homicidal ideations as well as auditory and visual hallucinations when he examined the patient. Interview revealed if it was not "Life threatening" he would not consult. Interview revealed he needed to make a correction on his documented examination of the patient, he denied performing a speculum examination as documented. Interview revealed the patient did not display self-injurious behaviors to warrant a psychiatric consult on her first. Interview revealed Patient #7 was stable for discharge. Interview revealed when she returned, she did have behaviors which were dangerous since she was in traffic which would warrant psychiatry to see her.

Interview on 05/12/2021 at 1350 with RN #1 revealed she was the primary nurse for Patient #7 on her first visit. Interview revealed she complained about having "bugs" her entire DED visit. Interview revealed she recalled when LEO brought Patient #7 back in to the DED, Patient #7 was in traffic trying to prevent cars from coming in the hospital parking lot. Interview revealed Patient # 7 was trying to prevent others from getting the "bugs". Interview revealed psychiatry was onsite and available for consults during Patient #7 first encounter.

Interview on 05/12/2021 at 1047 with LPCA #1 revealed in her professional opinion psychiatry should have been consulted on Patient #7 first visit. Interview revealed if seen the patient would have been recommended inpatient admission based on the medical record.

Based on policy reviews, closed medical record reviews, staff and physician interviews the hospital's dedicated emergency department (DED) failed to provide stabilizing treatment as required for 2 of 11 patients (Patient #5 and #7) who presented to the hospital's DED for psychiatric evaluation.

The findings included:

Review of the policy and procedure titled "EMTALA" reviewed 02/2020 revealed "Policy It is the policy of (Named) Health Care ("Hospital) that any individual who comes to the Hospital requesting examination or treatment for a medical condition is entitled to and will receive a Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) ...In compliance with EMTALA's objectives and requirements, it is the Hospital's express policy that, where an individual, regardless of his or her ability to pay, comes to the Hospital requesting examination or treatment for a medical condition, the Hospital, within its Capabilities will provide:-An appropriate Medical Screening Examination by a Qualified Medical Person...Necessary Stabilizing Treatment for an Emergency Medical Condition..."

1. Closed medical record review on 05/12/2021 revealed Patient #5 was a 12-year-old female who presented to the DED on 02/28/2021 at 1845 with complaints of lethargic, hot flashes, and dizzy. Review revealed a MSE started at 1846. Review of a Psychiatric Assessment dated 02/28/2021 at 1900 revealed "pt states has been feeling like hurting herself and show RN (registered nurse) healed/old self injury marks on left forearm, (sic) states she can't talk to her dad because she is afraid he will be disappointed in her...states family doesn't (sic) have extra money for counselors d/t (due to) mother is the only one working. Reports feels like if she was a boy she would be more confident. Suicide Attempt or Gesture Self-Injury..." Review of the Columbia Suicide Assessment dated 02/28/2021 at 1900 revealed "Q1. Wish to be dead Yes- in past month; Q2. Current suicidal thoughts Yes- in past month; Q3. Suicidal thoughts /c Method (no specific plan or intent) Not in past month; Q4. Suicidal Intent without Specific Plan Yes- in past month; Q5. Intent with Specific Plan Not in past month ...Q6. Suicidal Behavior in Past No; Risk Factors: Presenting Symptoms Anhedonia, Hopelessness/Despair, Anxiety and/or Panic; Precipitants/Stressors Inadequate Social Supports, Perceived Burden on Othrs; (sic) ...Columbia Suicide Severity Score 52; Columbia Suicidal Screen Risk Degree High Risk; Provider Notification: Provider Notified (named MD #2)." Review of MD #2's Provider Note dated 02/28/2021 at 2323 revealed "Chief Complaint: Psychiatric Stated Complaint: LETHARGIC/HOT FLASHES/DIZZY...Source: patient...History of Present Illness Presenting Illness: Description Patient presents the department (sic) with multiple complaints. She has been having dizziness episodes when she stands up as well as episodes where she feels a tingling sensation in her hands further goes on to complain of a nightmare type sensation that has been ongoing for the past several months which she has not been sleeping well...The patient did state that approximately 1 year ago, she was having suicidal thoughts and she had worked as a (sic) school counselor at that time and has been cleared of those thoughts since then has not been talking with a counselor recently...When the patient was interviewed outside of the dad, she does explain that she has been rather depressed recently and she has been cutting herself. She says that she has not been feeling suicidal recently however she has had these thoughts in the past. She has not told her parents that she has been cutting herself...She also is worried about disappointing her parents. She is unhappy with her looks and that she has been taking some of her mom ' s make-up. Today, her dad had found out about that and she had gotten in trouble for that today. She also is worried about disappointing her parents especially with her grades, apparently she is not doing well into (sic) classes. Review of systems...Psychiatric: Positive for: depression, stress; Negative for: suicidal ideation...Medical Decision Making Patient presents the department (sic) several concerns including feeling a dizzy (sic) and lightheaded as well as some depressive issues. When speaking away from the dad, the patient does complain of depressive issues as well as self-harm behavior. She is concerned about some issues with her appearance as well and feels like if she was a boy should be strong questioning some sexual identity issues. The patient does not want her parents know about this at this time. I did discuss with her about this including possibly using the school counselor now that she is back in school for assistance with this. She is in agreement with this. The patient was also further encouraged to discuss this more with her primary care provider. This point, (sic) the patient denied suicidal ideations does have forward thinking therefore she would not be required to stay in the emergency department overnight. She be (sic) discharged home with dad with primary care follow-up as an outpatient. She feels comfortable with this plan...Patient Instructions: (Named) Behavioral Health Discharge Resources, Near Syncope (ED). Referrals: (Named) PCP 2 to 4 Days..." Review of the Patient Visit Information signed (unable to make out signature) at 2125 revealed "You were seen today for: Dizziness...Follow-up Please contact the following to make an appointment for follow-up care: (Named PCP)..." Patient #1 was discharged home with her dad at 2129. The facility failed to ensure on 2/28/2021 that stabilizing treatment was provided as required for Patient #5 prior to discharge from the hospital emergency department. As the patient reported feelings of hurting self and showed the nurse current self- injury marks on her left forearm

Interview on 05/12/2021 at 1131 with MD #2 revealed Patient #5 did not present with any "acute concerns" such as suicidal ideations. Interview revealed Patient #1 did report self-cutting but nothing "acute." Interview revealed Patient #5 had seen her school counselor in the past which helped, and her PCP offered mental health services. MD #2 stated he had conversations with Patient #5's dad and he was on board with discharging and utilizing the school counselor and PCP. Interview revealed MD #2 usually offered the parents a psychiatric consult with minors, however he did not recall if he offered a psychiatric consult to Patient #5's father. Interview revealed if Patient #5 had reported active suicidal ideations, he would have held her in the DED overnight until a psychiatric consult was completed. Interview revealed MD #2 inquired several times to Patient #5 if she had suicidal thoughts, which she reported in the past but not currently.


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2. Closed medical record review on 05/12/2021 revealed Patient #7 (1st visit) was a 57-year-old female who presented to DED on 04/08/2021 at 0756. Review revealed at 0804 Triage Assessment "Pt brought to ED by EMS (emergency medical services). EMS reports that they were called for c/o (complaint of) vaginal bugs. Pt told EMS she has removed 14 bugs from her vagina that look like raviolie [sic]. On arrival pt reports she has had a man that has been threatening to kill her over money that her brother owes him for drugs. She took her cats and hid in the woods last nights to keep her cats safe. 'I'm ok with dying but I need protection for my cats and the sherriff [sic] wouldn't protect them.' Pt states 'There are many bugs out there and now I have them falling out of my vagina. I had 14 plops, loud plops fall out and they look like clear raviolie [sic]. Please get the rest out of me.' Pt reports last drank 2 nights ago. Last used meth a couple of days ago and cocaine last night." Review revealed MSE began at 0904. Review of "ED Provider Note" at 0904 revealed "Chief Complaint: Psychiatric; Stated Complaint: Bugs in Vagina; Presenting Illness Description: Patient is a 57-year -old female with a stated past medical history of PTSD (post-traumatic stress disorder), methamphetamine/cocaine/ ETOH (alcohol) abuse who presents via EMS with complaints of 'bugs are coming out of my vagina.' Patients states that this has been occurring 'all morning since she was in the woods last night. Patient is oriented but difficult to redirect. Patient states last methamphetamine used was last night. Patient describes vaginal discharge that is 'clear like ravioli's' that is remained stable since onset and denies any relieving factors. Patient denies any headaches, vision changes, tinnitus, sore throat, productive cough, shortness of breath... Physical Exam: Pelvic: External female genitalia without abnormalities, lesions, or rashes. Speculum exam shows no evidence of any parasites or abnormal discharge/blood in the vaginal vault....Medical Decision Making: Patient is a 57-year-old female who presents via EMS for vaginal parasitosis. Pelvic exam does not show any evidence of acute abnormalities internally or externally that would explain the sensation. Patient also upon discussion of discharge states that she has 'bugs in my ass'. Patient was given the opportunity to provide stool sample here in the emergency department...Patient denies any suicidal ideation, homicidal ideation, auditory/visual hallucinations. The patient has been reexamined and ready to be discharged..." Review of "Nursing Notes" at 0916 revealed "Pt very anxious and crying out that the bugs are all over her. Staff attempted to calm pt and gave the pt some body cleansing wiped to clean herself. Pt very concerned about her cats." Review of "Nursing Notes" at 1055 revealed "Pt sitting in chair in room. Nurse explained that she needed to get dressed and I will review the d/c (discharge) paperwork with her so she can go home." Review of "Nursing Notes" at 1118 revealed "Pt still sitting in chair, cleaning herself with cleansing wipes before getting dressed." Review revealed the patient was discharged at 1125 with instructions for Behavior Health Resources. Review of medical record revealed no psychiatric consult was ordered or conducted. The facility failed to ensure that patient #7 (visit one) was not stabilized as required prior to discharge on 5/12/2021.

Closed medical record revealed Patient #7 (2nd visit) returned to facility's DED on 04/08/2021 at 1325 (2 hours after discharge) via LEO (law enforcement officer) under IVC (involuntary commitment petition). Review revealed Patient #7 was escorted out of the hospital by security at discharge during her first encounter and she entered traffic around the hospital. Review of the IVC revealed "Patient was seen in this ED earlier in the day with a chief complaint of bugs everywhere inside of her and she busted a knuckle on her suitcase trying to get rid of the bugs...She presents to the ED under an IVC currently for these hallucinations and delusions secondary to meth use. Patient has no known psychiatric history...." Review revealed MSE began at 1342. Review revealed Psychiatric Consult was ordered and performed at 1426. Review revealed "Psychiatric Consult: Provisional Diagnosis: Substance - Induced Psychotic disorder; Impression Plan: Patient is recommended for IP psychiatric care due to exacerbated psychotic disorder with delusions secondary to methamphetamine use. IVC in place for safety." Review revealed Patient #7 was transferred to an inpatient psychiatric facility on 04/09/2021 at 0843.

Interview on 05/12/2021 at 1203 with MD #3 revealed he was the attending who performed MSE for Patient #7 in both visits. Interview revealed Patient #7 denied suicidal/ homicidal ideations as well as auditory and visual hallucinations when he examined the patient. Interview revealed if it was not "Life threatening" he would not consult. Interview revealed he needed to make a correction on his documented examination of the patient, he denied performing a speculum examination as documented. Interview revealed the patient did not display self-injurious behaviors to warrant a psychiatric consult on her first. Interview revealed Patient #7 was stable for discharge. Interview revealed when she returned, she did have behaviors which were dangerous since she was in traffic which would warrant psychiatry to see her.

Interview on 05/12/2021 at 1350 with RN #1 revealed she was the primary nurse for Patient #7 on her first visit. Interview revealed she complained about having "bugs" her entire DED visit. Interview revealed she recalled when LEO brought Patient #7 back in to the DED, Patient #7 was in traffic trying to prevent cars from coming in the hospital parking lot. Interview revealed Patient # 7 was trying to prevent others from getting the "bugs". Interview revealed psychiatry was onsite and available for consults during Patient #7 first encounter.

Interview on 05/12/2021 at 1047 with LPCA #1 revealed in her professional opinion psychiatry should have been consulted on Patient #7 first visit. Interview revealed if seen the patient would have been recommended inpatient admission based on the medical record.