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Based on interview and record review, the facility failed to follow their policies and procedures and did not perform a Medical Screening Exam (MSE) on one patient (#18), within the facility's capabilities to determine if an emergency psychiatric/medical condition existed. This occurred on one patient (#18) out of 33 Emergency Department (ED) patient medical records reviewed from May 2013 to October 2013. The facility census was 103, the average daily ED census over the past six months was 85 and the average monthly ED census over the last six months was 2,573.

Findings included:

1. Record review of the facility's policy titled, "Treatment & Transfer of Individuals who Request Emergency Medical Services" revised 07/07/06, showed the following direction for facility staff:
-Emergency medical condition means:
-A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy.
-Medical Screening Examination:
-The medical screening examination shall be performed by a physician or a Qualified Medical Person (QMP). The physician or QMP shall determine within reasonable clinical confidence whether the individual has an emergency medical condition, utilizing services within the capability of the ED, using ancillary services and resources routinely available in the ED for individuals with similar symptoms.
-Qualified Medical Person means an individual who is licensed or certified and has demonstrated current competence in the performance of a MSE. The QMP working in the ED is under the supervision of the ED physician.
-Stable for discharge means:
-The physician has determined that the patient has reached the point where his/her continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instructions; or
-With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to him/herself or others.

2. Record review of the facility's policy titled, "Psychiatric Evaluation Nurse (PEN)" dated 02/28/11, showed that the PEN is available to the ED for patients who are questionable for meeting admission criteria.

3. Record review of the facility's "Medical Staff Rules and Regulations" showed the following information:
-Individuals Authorized to Perform Initial Medical Screening: The following are authorized to conduct the initial medical screening for an emergency medical condition when an individual presents to the Hospital:
-Medical Staff Members;
-Emergency Trauma Center Registered Professional Nurses;
-Labor & Delivery Triage Registered Professional Nurses;
-Psychiatric Evaluation Nurses;
-Advanced Practice Nurses;
-Physician Assistants.

4. Record review of a closed ED record showed the following information:
-Patient #18 presented to the facility's ED on Tuesday, October 8, 2013 at 2:27 PM, with complaints of suicidal ideation (SI).
-The local police accompanied the patient and reported to the ED staff that the patient's girlfriend broke up with him three days ago and that he was homeless and reported he was going to jump off a bridge.
-The police presented ED staff with paperwork for a 96 hour hold due to the patient's threat of self-harm.
-At 2:31 PM, Paramedic P documented the patient had a plan and means for self-harm and that his suicide prevention score was "2".
-At 2:33 PM, a diagnostic EKG (tracing of the heart rhythm) was obtained which revealed the patient had an abnormal heart rhythm when compared to a tracing performed on 09/05/13.
-At 2:45 PM, blood was obtained for testing (ED physician L later canceled the testing).
-At 2:52 PM, ED physician L examined the patient and documented the patient stated that he had a history of bipolar affective disorder (mood swings from mania to depression), Post Traumatic Stress Disorder (PTSD-anxiety disorder), a history of psychosis (mental illness characterized by radical changes in personality), substance abuse, alcohol dependence, homicidal ideation, high blood pressure, coronary artery disease, and prior placement of stents to open blocked coronary arteries.
-Further documentation by ED physician L showed the patient had been on Seroquel (antipsychotic medication used to treat bipolar disorder) and Celexa (antidepressant) and that the patient reported that the "Celexa doesn't work."
-At the end of the exam by ED physician L, the patient expressed some concern that he will be "missing a court date today."
-Review of ED physician L's Medical Decision Making Plan of Care showed he spoke with the patient about the inability to place him in the behavioral health unit (BHU); that he talked with the patient about options; and that the patient reported he felt safe going home and denied any suicidal or homicidal ideations.
-ED physician L documented he provided the patient with a prescription for Seroquel, instructions to follow-up at a local mental health center or return to the ED should he have increased problems, and that the patient was comfortable with this plan.
-At 3:12 PM, Paramedic P documented that the patient reported the following:
-His Seroquel was not working.
-He was angry with his psychiatrist because he did not listen to him about what is going on inside of his head.
-He would "jump" off a bridge if he was going to kill himself.
-He has tried to kill himself before.
-He had drunk one 16 ounce beer today.
-At 3:44 PM, Paramedic P documented she spoke with ED physician L who confirmed he was aware the patient presented to the ED with police and "96 hour hold paperwork."
-At 3:50 PM, Paramedic P documented the following:
-The patient at discharge reported "No improvement."
-The patient received a copy of discharge instructions, which read "Your diagnoses were DEPRESSION and ETOH (alcohol) ABUSE".
-"Your vitals were last recorded, BP (blood pressure) 207/107 (normal blood pressure is 120/80)".
-Further review of the patient's ED record showed that Paramedic P documented the patient had a blood pressure of 197/120 at 3:44 PM. The medical record did not contain evidence the patient received further examination for his abnormal EKG or elevated blood pressure or that his psychiatrist, the psychiatric evaluation nurse (PEN), or the on-call psychiatrist was contacted to provide further examination sufficient to determine if the patient had an emergency psychiatric/medical condition prior to his discharge from the facility.

5. Record review of Hospital B's medical record showed Patient #18 presented to the ED on Tuesday, October 08/13 around 6:00 PM, and was admitted for treatment to stabilize his emergency psychiatric/medical condition.

6. During an interview on 10/31/13 at 10:45 AM, Staff D, Registered Nurse (RN), ED Trauma Coordinator, stated that the patient presented to the ED with an affidavit for a 96 hour hold from the local police. Staff D stated that it would be up to the ED physician to initiate if it was felt like the patient needed to be put on a 96 hour hold. Staff D stated that it would then be the ED physician's responsibility to get a judge to sign the 96 hour hold request form.

7. During an interview on 10/31/13 at 11:35 AM, Staff L, ED Physician, stated that if a patient comes into the ED with the police and the police have an affidavit it would be his responsibility to evaluate and assess the patient to determine if the patient needed to continue with a 96 hour hold. Staff L stated that as he talked more and more with Patient #18 it became apparent that the patient was not suicidal and specifically denied harming himself. Staff L stated that he felt like the patient's verbal suicide threat was a "ploy" to miss a court date he had that day. Staff L stated that after talking to the patient and getting to the bottom of why he was brought into the ED, the patient stated that he needed an excuse to miss his court date and needed a script for his medications. Staff L stated that patient reported to him that he was out of his psychiatric medication Seroquel. Staff L stated that the patient denied to him having any current thoughts of suicide. Staff L stated that the patient reported that he felt safe to be discharged from the facility. Staff L stated that the patient was discharged with a script for the needed psychiatric medication. Staff L stated that at no time during his interactions or assessments with the patient did he feel like the patient was at risk to harm self or others. Staff L stated that he does not know what the suicide precaution score of 2 is or what it indicates. Staff L stated that the facility did not have a tool to assess psychiatric patients. Staff L stated that he relies on his 20 years of experience to evaluate psychiatric patients. Staff L stated that he has kept psychiatric patients in the past until placement could be found.

8. During an interview on 10/31/13 at 3:10 PM, Staff P, ED Paramedic, stated that she performed the initial assessment on Patient # 18. She stated that his chief complaint was anxiety and he needed a refill of his medications. She stated that during his assessment he stated that he was suicidal. She stated that the patient's blood pressure was 197/120 at discharge. She stated she notified Staff L, ED physician, of the blood pressure but it was not her habit to document that she had informed him. She stated that she did not remember what the physician replied when she told him.

9. During a telephone interview on 11/01/13 at 10:05 AM, Staff L, ED physician, stated that he was aware of the increased blood pressure of Patient # 18. He stated that the patient was asymptomatic; if the patient was symptomatic, he would look at his increased blood pressure differently. Staff L stated that he always asks for a bed from the Behavioral Health Unit even when he had not made a complete assessment of a patient. He stated he did so because beds were at such a premium that he wanted to secure a bed if a patient needed to be admitted.

10. During an interview on 11/01/13 at 10:25 AM, Staff O, ED Physician, stated that he sometimes will call the BHU to try to secure a bed if one is available for a psychiatric patient. Staff O stated that it is common practice to try to secure a bed as soon as a possible for psychiatric patients. Staff O stated that the ED physicians do not have a psychiatric tool to assess or evaluate psychiatric patients. Staff O stated that if he had concerns he could always ask a psychiatric nurse to evaluate the patient of concern even if the patient will not be admitted to the BHU.

Based on interview and record review, the facility failed to follow their policies and procedures and did not perform a Medical Screening Exam (MSE) on one patient (#18), within the facility's capabilities to determine if an emergency psychiatric/medical condition existed. This occurred on one patient (#18) out of 33 Emergency Department (ED) patient medical records reviewed from May 2013 to October 2013. The facility census was 103, the average daily census of the Emergency Department over the past six months was 85 and the average monthly census over the last six months was 2,573.

Findings included:

1. Record review of the facility's policy titled, "Treatment & Transfer of Individuals who Request Emergency Medical Services" revised 07/07/06, showed the following direction for facility staff:
-Emergency medical condition means:
-A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy.
-Medical Screening Examination:
-The medical screening examination shall be performed by a physician or a Qualified Medical Person (QMP). The physician or QMP shall determine within reasonable clinical confidence whether the individual has an emergency medical condition, utilizing services within the capability of the ED, using ancillary services and resources routinely available in the ED for individuals with similar symptoms.
-Qualified Medical Person means an individual who is licensed or certified and has demonstrated current competence in the performance of a MSE. The QMP working in the ED is under the supervision of the ED physician.
-Stable for discharge means:
-The physician has determined that the patient has reached the point where his/her continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instructions; or
-With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to him/herself or others.

2. Record review of the facility's policy titled, "Psychiatric Evaluation Nurse (PEN)" dated 02/28/11, showed that the PEN is available to the ED for patients who are questionable for meeting admission criteria.

3. Record review of the facility's "Medical Staff Rules and Regulations" showed the following information:
-Individuals Authorized to Perform Initial Medical Screening: The following are authorized to conduct the initial medical screening for an emergency medical condition when an individual presents to the Hospital:
-Medical Staff Members;
-Emergency Trauma Center Registered Professional Nurses;
-Labor & Delivery Triage Registered Professional Nurses;
-Psychiatric Evaluation Nurses;
-Advanced Practice Nurses;
-Physician Assistants.

4. Record review of a closed ED record showed the following information:
-Patient #18 presented to the facility's ED on Tuesday, October 8, 2013 at 2:27 PM, with complaints of suicidal ideation (SI).
-The local police accompanied the patient and reported to the ED staff that the patient's girlfriend broke up with him three days ago and that he was homeless and reported he was going to jump off a bridge.
-The police presented ED staff with paperwork for a 96 hour hold due to the patient's threat of self-harm.
-At 2:31 PM, Paramedic P documented the patient had a plan and means for self-harm and that his suicide prevention score was "2".
-At 2:33 PM, a diagnostic EKG (tracing of the heart rhythm) was obtained which revealed the patient had an abnormal heart rhythm when compared to a tracing performed on 09/05/13.
-At 2:45 PM, blood was obtained for testing (ED physician L later canceled the testing).
-At 2:52 PM, ED physician L examined the patient and documented the patient stated that he had a history of bipolar affective disorder (mood swings from mania to depression), Post Traumatic Stress Disorder (PTSD-anxiety disorder), a history of psychosis (mental illness characterized by radical changes in personality), substance abuse, alcohol dependence, homicidal ideation, high blood pressure, coronary artery disease, and prior placement of stents to open blocked coronary arteries.
-Further documentation by ED physician L showed the patient had been on Seroquel (antipsychotic medication used to treat bipolar disorder) and Celexa (antidepressant) and that the patient reported that the "Celexa doesn't work."
-At the end of the exam by ED physician L, the patient expressed some concern that he will be "missing a court date today."
-Review of ED Physician L's Medical Decision Making Plan of Care showed he spoke with the patient about the inability to place him in the behavioral health unit (BHU); that he talked with the patient about options; and that the patient reported he felt safe going home and denied any suicidal or homicidal ideation's.
-ED physician L documented he provided the patient with a prescription for Seroquel, instructions to follow-up at a local mental health center or return to the ED should he have increased problems and that the patient was comfortable with this plan.
-At 3:12 PM, Paramedic P documented that the patient reported the following:
-His Seroquel was not working.
-He was angry with his psychiatrist because he did not listen to him about what is going on inside of his head.
-He would "jump" off a bridge if he was going to kill himself.
-He has tried to kill himself before.
-He had drunk one 16 ounce beer today.
-At 3:44 PM, Paramedic P documented she spoke with ED physician L who confirmed he was aware the patient presented to the ED with police and "96 hour hold paperwork."
-At 3:50 PM, Paramedic P documented the following:
-The patient at discharge reported "No improvement."
-The patient received a copy of discharge instructions, which read "Your diagnoses were DEPRESSION and ETOH (alcohol) ABUSE".
-"Your vitals were last recorded, BP (blood pressure) 207/107 (normal blood pressure is 120/80)".
-Further review of the patient's ED record showed that Paramedic P documented the patient had a blood pressure of 197/120 at 3:44 PM. The medical record did not contain evidence the patient received further examination by the physician for his abnormal EKG or elevated blood pressure or that his psychiatrist, the psychiatric evaluation nurse (PEN), or the on-call psychiatrist was contacted to provide further examination sufficient to determine if the patient had an emergency psychiatric/medical condition prior to his discharge from the facility.

5. Record review of Hospital B's medical record showed Patient #18 presented to the ED on Tuesday, October 08/13 around 6:00 PM and was admitted for treatment to stabilize his emergency psychiatric/medical condition.

6. During an interview on 10/31/13 at 10:45 AM, Staff D, Registered Nurse (RN), ED Trauma Coordinator, stated that the patient presented to the ED with an affidavit for a 96 hour hold from the local police. Staff D stated that it would be up to the ED physician to initiate it if it was felt like the patient needed to be put on a 96 hour hold. Staff D stated that it would then be the ED physician's responsibility to get a judge to sign the 96 hour hold request form.

7. During an interview on 10/31/13 at 11:35 AM, Staff L, ED Physician, stated that if a patient comes into the ED with the police and the police have an affidavit it would be his responsibility to evaluate and assess the patient to determine if the patient needed to continue with a 96 hour hold. Staff L stated that as he talked more and more with Patient #18 it became apparent that the patient was not suicidal and specifically denied harming himself. Staff L stated that he felt like the patient's verbal suicide threat was a "ploy" to miss a court date he had that day. Staff L stated that after talking to the patient and getting to the bottom of why he was brought into the ED, the patient stated that he needed an excuse to miss his court date and needed a script for his medications. Staff L stated that patient reported to him that he was out of his psychiatric medication Seroquel. Staff L stated that the patient denied to him having any current thoughts of suicide. Staff L stated that the patient reported that he felt safe to be discharged from the facility. Staff L stated that the patient was discharged with a script for the needed psychiatric medication. Staff L stated that at no time during his interactions or assessments with the patient did he feel like the patient was at risk to harm self or others. Staff L stated that he does not know what the suicide precaution score of 2 is or what it indicates. Staff L stated that the facility did not have a tool to assess psychiatric patients. Staff L stated that he relies on his 20 years of experience to evaluate psychiatric patients. Staff L stated that he has kept psychiatric patients in the past until placement could be found.

8. During an interview on 10/31/13 at 3:10 PM, Staff P, ED Paramedic, stated that she performed the initial assessment on Patient # 18. She stated that his chief complaint was anxiety and he needed a refill of his medications. She stated that during his assessment he stated that he was suicidal. She stated that the patient's blood pressure was 197/120 at discharge. She stated she notified Staff L, ED physician, of the blood pressure but it was not her habit to document that she had informed him. She stated that she did not remember what the physician replied when she told him.

9. During a telephone interview on 11/01/13 at 10:05 AM, Staff L, ED physician, stated that he was aware of the increased blood pressure of Patient # 18. He stated that the patient was asymptomatic; if the patient was symptomatic, he would look at his increased blood pressure differently. Staff L stated that he always asks for a bed from the Behavioral Health Unit even when he had not made a complete assessment of a patient. He stated he did so because beds were at such a premium that he wanted to secure a bed if a patient needed to be admitted.

10. During an interview on 11/01/13 at 10:25 AM, Staff O, ED Physician, stated that he sometimes will call the BHU to try to secure a bed if one is available for a psychiatric patient. Staff O stated that it is common practice to try to secure a bed as soon as a possible for psychiatric patients. Staff O stated that the ED physicians do not have a psychiatric tool to assess or evaluate psychiatric patients. Staff O stated that if he had concerns he could always ask a psychiatric nurse to evaluate the patient of concern even if the patient will not be admitted to the BHU.