HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to provide an appropriate mental health screening examination (MHSE), to determine if Pt. #1 was experiencing a psychiatric medical emergency. See A-2406.

The Immediate Jeopardy (IJ) was identified on 4/02/2024 at 42 CFR 489.24 due to the hospital's failure to appropriately examine a patient's psychiatric complaint while in the ED (emergency department). Subsequently, Pt. #1 fatally stabbed another person after discharge from the ED. The IJ was announced on 4/2/2024 at 3:35 PM during a meeting with the hospital's President, the Director of Quality Safety Accreditation, the Accreditation and Regulation Specialist, and the Director for Center for Mental Health, and was not removed by the survey exit date of 4/2/2024.

Based on document review and interview, it was determined that for 1 of 12 patients' (Pt. #1) clinical records reviewed with psychiatric complaints seeking care in the emergency department (ED), the hospital failed to provide an appropriate mental health screening examination (MHSE), to determine if Pt. #1 was experiencing a psychiatric medical emergency. Subsequently, Pt. #1 fatally stabbed another person after discharge from the ED.

Findings include:

1. On 3/28/2024, the hospital's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department, Labor and Delivery, And Behavioral Health Services" (4/2022) was reviewed and indicated, " ...V... E ... Psychiatric patients presenting to the Emergency Department ... will receive a MSE and/or MHSE ... J ... 2. (MHSE is the) process i.e., studies, testing, procedures, etc. required to determine, within reasonable clinical confidence, whether or not an individual is experiencing a psychiatric medical emergency. 3 ... The MHSE must be performed by a physician Member of the Medical Staff, or by a physician assistant or advance practice nurse working under the direction of a physician member of Medical Staff ..."

2. On 3/28/2024, the hospital's policy titled, "Suicide Prevention and Assessment" (6/2023) was reviewed and indicated, "I ... Suicide Assessment Five Step Evaluation and Triage (SAFE-T) - suicide risk assessment tool used when a patient has a positive screen (Yes answer to Columbia Suicide Severity Rating Scale/C-SSRS) ... Special Needs Unit (SNU) - Area located in the ED that is a preferred non-dedicated behavioral health space to ... mental health patients ... VI ... C ... 2 ... a. Assessment within the ED setting ... 2. When the patient arrives in the SNU, the SNU RN will complete the SAFE-T assessment for suicidality ... 3. The A&R staff will be consulted to complete a psychiatric evaluation ...c. Assessment requiring the Psychiatric Setting: 1) If the patient is moderate to high suicide risk level according to the SAFE-T assessment ... the patient may sign themselves into inpatient services voluntarily. 2) If the patient is moderate to high suicide risk level according to the SAFE-T assessment and ready for transfer but refuses admission ... (Petition and Certificate for Involuntary Admission will be completed) ..."

3. On 3/28/2024, the SAFE-T Card from Substance Abuse and Mental Health Services Administration (SAMSHA) (2023), was reviewed and indicated that Risk factors for suicide include: Suicidal behavior, e.g., history of prior suicide attempt; Current/past psychiatric disorders, e.g., mood disorder, aggression, PTSD (post-traumatic stress disorder); Symptoms, e.g., anhedonia (social withdrawal), hopelessness; Precipitants/Stressors, e.g., loss of financial status, history of physical or sexual abuse, social isolation; and Change in Treatment, e.g., discharge from psychiatric hospital. Suicidal intent is the extent to which the patient expects to carry out the plan. For patients having multiple risk factors, including suicidal ideation with plan, level of suicide risk is Moderate.

4. On 3/28/2024, the clinical records for Pt. #1 was reviewed. Pt. #1 had two ED encounters: 3/23/2024 and 3/24/2024. The clinical records indicated:

On 3/23/2024 at 12:50 AM, Pt. #1 was brought to the hospital's ED by EMS (emergency medical services) due to abdominal pain. Pt. #1 was treated with intravenous fluids due to elevated CPK (muscle tissue enzymes). While in the ED, Pt. #1 was evaluated by a crisis counselor due to depression and anxiety. The clinical impression for Pt. #1 was non-traumatic rhabdomyolysis (muscle tissue injury) and anxiety. On 3/23/2024 at approximately 8:09 AM, the hospital discharged and arranged a cab to take Pt. #1 to an outpatient voluntary mental health program for people experiencing psychiatric crisis.

On 3/24/2024 at approximately 11:43 AM, Pt. #1 was brought back to the hospital's ED by EMS from the voluntary outpatient mental health program. A petition for involuntary admission accompanied Pt. #1 that indicated, "(Pt. #1) reports (Pt. #1 have) ideations ... (Pt. #1) reported (Pt. #1) will walk outside right now and stab (self) in the head. (Pt. #1) also stated (Pt. #1) will shoot (self) in the head 100 times. (Pt. #1) will do whatever it takes to kill (self). (Pt. #1) was angry and swearing ... demanded hospitalization ..."

- At 11:45 AM, the ED triage note indicated that Pt. #1 had a complaint of psychiatric problem and suicidal ideation. The ESI (emergency severity index) was 2 (needs emergent treatment). The nurse's C-SSRS Screening for Pt. #1 was high risk for suicide.

- At 11:47 AM, the advance practice provider's note indicated that Pt. #1 reported (Pt. #1) is suicidal and has a plan for somebody else to shoot (Pt. #1). Pt. #1 was transferred to SNU Bed 19.

- At 12:24 PM, E #2's (SNU RN) note indicated, "Suicide Reassessment. You indicated that you previously had thoughts of suicide. Are you having those thoughts today? (Patient's response: Yes). When you think of suicide, do you have a plan to act on those thoughts? (Patient's response: Yes) ..."

- At 12:27 PM, E #2's SAFE-T Assessments indicated that risk factors included mood disorders, hopelessness, social isolation, and discharge from a psychiatric hospital. Although Pt. #1 verbalized suicidal ideation with plan, that Pt. #1 will walk outside right now and stab self in the head, that Pt. #1 will shoot (self) 100 times, and that Pt. #1 will do whatever it takes to kill (self), E #2 documented that Pt. #1 only had thoughts of death and no plan. E #2's SAFE-T suicide risk assessment level was rated as Low.

- At 12:29 PM, E #3 (ED Nurse Practitioner) wrote, " ... Chief Complaint: Psychiatric Problem, Suicidal ... has been without (psychiatric) medications for 2-3 days. States ... supposed to go to (a) homeless shelter but there is no room for (Pt. #1) ... (Pt. #1) was (at a voluntary outpatient program) ... Review of Systems ... Affect is flat ... Behavior is agitated ... Thought Content includes suicidal ideation ... Thought content includes suicidal plan ... ED Course ... (At 12:26 PM) ... (Pt. #1) have some depression. (Pt. #1) is sad because (Pt. #1) cannot find a place to reside (Pt. #1) is homeless ... (At 12:53 PM), resources given for homeless shelters and overnight café. (At 1:09 PM), (outpatient program) called and declined (Pt. #1) and noted that (Pt. #1) did not meet the criteria. Impression: 1. Depression, Unspecified; 2. PTSD (Post-Traumatic Stress Disorder) ..."

- At 12:29 PM, E #1 (Assessment and Referral/Crisis Counselor) documented "Presenting problem (per patient). (Pt. #1) presented to the ED ... with suicidal thoughts. (Pt. #1) plans to shoot (self) ... (Pt. #1) is homeless. (Pt. #1) has a history of suicide attempts by hanging (self). (Pt. #1) states (Pt. #1) is 'a very intelligent person and knows how to do things.' (Pt. #1) was at (Name of Another Hospital) on 3/11/2024 for 5 days. (Pt. #1) reports (Pt. #1) do not have access to (Pt. #1's) medications because they are at a pharmacy ... (Pt. #1) reports being out of ... medications for 2-3 days. ... (Pt. #1) reports being diagnosed with PTSD and Depression ... Clinician perspective and observation of presenting problems ... (Pt. #1) ... has poor hygiene habits ... evidenced by ... bad body odor ... (Pt. #1) did not make eye contact while being assessed ... (Pt. #1) needed to be asked some questions multiple times ... to answer ... (Pt #1) is malingering (producing false/exaggerated medical symptoms) and just wanting a place to sleep ... Consulted with (E #3/ED Nurse Practitioner) and (MD #1/Psychiatrist). Patient Disposition: Discharged. Plan of Care: Per providers, (Pt. #1) does not meet inpatient criteria and is recommended to discharge ..."

- At 1:34 PM, E #2 documented, "(Pt. #1) provided with discharge paperwork and informed that (Pt. #1) would be discharged ... (Pt. #1) given time to read ... paperwork. (Pt. #1) preceded to fall back asleep. This RN entered room once more to inform (Pt. #1) that (Pt. #1) has been discharged. (Pt. #1) stating (Pt. #1) was unaware and has not seen a provider yet. Security escorted (Pt. #1) out of SNU ..."

- Other than E #1's notes, there was no documentation that a MHSE was performed by qualified medical personnel.

5. On 3/28/2024 at approximately 11:00 AM, E #6 (Director of Quality) stated that the hospital has not completed an investigation regarding Pt. #1.

6. On 3/28/2024 at approximately 2:37 PM, on 3/29/2024 at approximately 10:25 AM, and on 3/29/2024 at approximately 1:45 PM, interviews were respectively conducted with E #1 (Assessment and Referral/Crisis Counselor), E #2 (SNU RN), and E #3 (ED NP). E #1, E #2, and E #3 all stated that they asked and gathered the same information regarding Pt. #1. E #1 stated, "I spoke with the psychiatrist. (MD #1) agreed that the patient will not require hospitalization. And the plan was to discharge (Pt. #1)." E #1 and E #2 stated that Pt. #1 was low risk for suicide because Pt. #1 did not have access to a gun. E #3 did not speak with the psychiatrist. E #3 stated that E #3's responsibility was to assess if Pt. #1 was having an emergency medical condition. E #1, E #2, and E #3 stated that since Sunday, 3/24/2024, they have not received any in-service nor have been made aware of any changes regarding examination or assessment of psychiatric patients in the ED.

7. On 3/29/2024 at approximately 9:34 AM, an interview was conducted with E #4 (Director of Center for Mental Health/SNU). When shown Pt. #1's presenting problems, assessment and referral notes, including SAFE-T assessment of E #2, E #4 agreed that Pt. #1 had multiple risk factors as well as suicidal ideation and plan, which are elements for Moderate Level for Suicide Risk. E #4 stated that the SAFE-T suicide risk level is considered whether a patient will be admitted to the hospital.

8. On 3/29/2024 at approximately 12:00 PM, an interview was conducted with MD #1 (Psychiatrist). MD #1 stated that E #1 called and stated that Pt. #1 denied suicidal and homicidal ideation and did not require hospitalization. MD #1 stated that criteria for hospitalization includes if a patient is suicidal and has a plan, as well as if a patient is depressed. When read to MD #1 the petition for involuntary admission and the assessments of E #1 and E #3, MD #1 stated that MD #1 did not see Pt #1's medical record. MD #1 stated what was reported was that Pt. #1 was not suicidal, was malingering, and Pt. #1 did not require hospitalization. When asked regarding appropriate SAFE-T level for Pt. #1, MD #1 stated that the level could be Moderate Risk for Suicide.