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Based on hospital policy review, medical record review, physicians and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

Based on policy and procedure review, medical record review, and staff and physician interviews, hospital staff delayed stabilization for one (1) of 20 emergency department patients by allowing a patient under involuntary commitment to sign out and leave against medical advice, (Patient #14).

~ Cross refer to A2407.

Based on policy and procedure review, medical record review and staff and physician interviews, hospital staff delayed stabilization for one (1) of 20 emergency department patients by allowing a patient under involuntary commitment to sign out and leave against medical advice (AMA), (Patient #14).

The findings included:

Review of the Emergency Medical Treatment and Labor Act (EMTALA) policy, last revised 04/2020, revealed "...If the medical screening exam reveals that an emergency medical condition exists, (Hospital Initials) will then provide all such patients with treatment necessary to stabilize this condition. ..."

Dedicated Emergency Department (DED) medical record review, on 2/14/2023, revealed Patient #14 arrived to the DED on 02/06/2023 at 1337 via Emergency Medical Services (EMS) from home and was checked in to an Emergency Department (ED) room. Review of a Rapid Initial Screening by a Registered Nurse (RN) at 1524 revealed Patient #14 was brought in for suicidal ideation. Review revealed Patient #14 had a past medical history that included "Parkinson's (progressive disorder of the Central Nervous System affecting movement), schizoaffective /bipolar (chronic mental illnesses)" and had been discharged from the hospital psychiatry unit that morning. Review of an Emergency Provider Record, signed 02/06/2023 at 1626, revealed "...Time Seen By Provider: 16:21.... Chief Complaint: Suicidal ....This is a 60-year-old male with a known history of schizophrenia, was just discharged from hospital today this a.m..... patient states that he still wants to kill himself and that he has been having auditory hallucinations....Discussed with..... Psychiatry.... Decision regarding hospitalization was made ....Diagnosis: 1. Schizophrenia exacerbation.... Primary Impression: Chronic schizophrenia Disposition Type: Hospitalize. ..." Review of Involuntary Commitment paperwork revealed a "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" which documented the first-level examination and evaluation for Patient #14 was conducted 02/06/2023 at 1600. Review revealed it showed the patient needed Inpatient commitment because the patient was "...An Individual with a mental illness" and "Dangerous to: ... Self or...Others." The findings listed were "Schizophrenic with Auditory hallucinations & S.I (Suicidal Ideation). ..."

Review of a "Provider Progress Note" by a psychiatrist, electronically signed 02/08/2023 at 0912, revealed"...Date Seen: 2/8/23 Interval History: ....male with schizoaffective disorder and significant behavioral challenges continues to have mood lability and is adamant about wanting to be in a different hospital IVC (involuntary commitment) paperwork was filled out and he is waiting to be transferred to another hospital no side effects reported on current medication .... Anticipated Discharge Date: Feb 22, 2023 .... Mental Status .... alert oriented x 3 mood is okay affect is constricted thought process is labile denies any current suicidal homicidal thoughts .... insight and judgment limited ... Problems List (1) Schizoaffective disorder....Will continue current medications he is waiting to be transferred to another hospital.... Current Suicide Risk: Medium....Expected Length of Stay ....6-8 Days....Clinical Pain (sic) /Reasoning Based on direct contact with the patient, I certify in my best clinical judgement that continued care in an Inpatient is warranted. Evidence for continue care is: Abnormal MSE (Medical Screening Exam). ..."

On 02/08/2023 at 1537, Paramedic #14 documented, "Pt became upset when he saw another pt (patient) leaving and said we should find him a place before we find someone else a place.... He said that we were not trying. I told him that was not true but he has to understand that him coming back to back to hospital make people suspect he is homeless and maligering (sic) so they may not think he really want (sic) help. Pt said he will just die in here then. He said yall (sic) aren't giving me the help I need. I told him that we are and have treated him for what he tell (sic) us is the problem and he is better when we discharge him .... Pt yelled and stomped off to his room, saying I would rather kill myself than be here."

On 02/08/2023 at 1641, an Emergency Department note documented by Paramedic #14, "Pt is adament (sic) that he no longer want to be here. He want to go to another facility. I called (where pt lived) owner and informed her of pt request to be sent to another hospital. I told her we had referred him out but there are no takers at this time. I told her we would continue to refer him out and has continued to offer pt further treatment here and will continue to but he is adament (sic) he don't want help from here and we are not helping him. I told her the pt want to know if she will come pick him up and take him to (hospital name). She said she would not unless she knew they were going to keep him....I asked her did pt have money left for him to take a cab to another facility if he requested to go. She said yes. He was grown, his on (sic) guardian and she was not going to spend her time taking him to another hospital I told her I would inform the pt. I also advised Dr. (Name)."

On 02/08/2023 at 1707 Paramedic #14 documented, revealed "Safety Cab called and asked for an estimate for transport to (Hospital name). Pt and ...owner (Name) informed of estimate....We continued to encourage pt to be patient. He continued to refuse care at this facility. Dr. (Name) talked to pt again and again tried to get pt to stay until he could be accepted at another facility. Pt said no he was ready to leave and leave right now. He continued to say we were not doing anything for him here."

On 02/08/2023 at 1741 Paramedic #14 documented in another note that stated "Pt discharged AMA (against medical advice) by charge nurse. Pt was given his belongings and let off of unit by myself." Review of IVC Status "NOTICE OF COMMITMENT CHANGE", signed on 02/08/2023 (no time documented), revealed Patient #14's name was listed as the Respondent. The form included a listing of reasons that the involuntary commitment might be changed with a box to be checked by the appropriate reason(s) for the change. Review of the document revealed none of the boxes were checked but beside the last box which was labeled "Other (Specify)" were the handwritten words "AMA discharge" signed by a provider.

Interview on 02/17/2023 at 1445, with RN # 13, revealed he was the ED Charge Nurse on 02/08/2023. Interview revealed RN #13 was called by Paramedic #14 who indicated she had communicated with the psychiatrist. Interview revealed RN #13 understood there was a change in commitment and the patient was allowed to sign AMA. RN #13 stated he thought when Patient #14 left, he "just walked out" of the ED.

Interview on 02/17/2023 at 1515 with Paramedic #14 revealed Patient #14 had just been discharged from the inpatient psychiatric unit that day. Interview revealed the patient "signed himself back in" but did not want to be treated at this hospital. Interview revealed the plan was to refer him out to another hospital and treat him while he awaited the transfer. Paramedic #14 stated the patient wanted to know why other facilities were not taking him, stated he was not being helped here, and demanded to leave. Interview revealed MD #1 stated he could leave AMA. Interview revealed Patient #14 walked out out of the facility, he was his own guardian, so he was allowed to walk out

Telephone interview, on 02/17/2023 at 1545, with Medical Doctor (MD) # 1, the psychiatrist who saw Patient #14 in the DED, revealed Patient #14 was discharged from the inpatient psychiatric unit and came back to the DED the same day (02/06/2023). Interview revealed the ED physician consulted MD #1. Interview revealed MD #1 suggested the patient be placed on IVC for transfer to another hospital because Patient #14 refused care at this hospital. Patient #14, the psychiatrist stated, wanted transfer but was not patient enough to wait until a transfer was available. On 02/08/2023 Patient #14 started demanding transfer or discharge immediately. Interview revealed Patient #14 was not overly psychotic and refused to wait so MD #1 agreed he could go AMA (against medical advice). In response to a question about discharge, interview revealed "no" because Patient #14 needed care, he had deep psychological needs. Interview revealed MD #1 wrote AMA Discharge on the change of commitment form and thought it rescinded the IVC.

In summary, Patient #14 arrived by EMS to the DED on 02/06/2023 at 1337 after having been discharged from the inpatient psychiatric unit earlier that day. Patient #14 was placed under involuntary commitment and remained in the DED on a crisis stabilization unit. On 02/08/2023 at 0912, Patient #14 was seen by the psychiatrist who indicated he should remain under IVC to be transferred to another facility because he needed inpatient care. Later that day he was allowed to sign out AMA which potentially delayed stabilization of the patient's condition.