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Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide a Medical Screening Examination (MSE) for one patient (#8), within the hospital's capability and capacity to determine if an Emergency Medical Condition (EMC) existed. A total of 30 Emergency Department (ED) medical records were reviewed of patients that presented to the hospital's dedicated ED seeking care/treatment out of a sample selected from April 2020 to September 2020. This failure had the potential to affect all patients that presented to the hospital's dedicated ED seeking medical care/treatment. The hospital's ED had an average monthly census of 1,500 patients.


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Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide a Medical Screening Examination (MSE) for one patient (#8), within the hospital's capability and capacity to determine if an Emergency Medical Condition (EMC) existed. A total of 30 Emergency Department (ED) medical records were reviewed of patients that presented to the hospital's dedicated ED seeking care/treatment out of a sample selected from April 2020 to September 2020. This failure had the potential to affect all patients that presented to the hospital's dedicated ED seeking medical care/treatment. The hospital's ED had an average monthly census of 1,500 patients.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Screening Examinations," revised 08/27/19, showed that:
- Any individual who presents to the hospital, and who requests the examination of, or treatment for, an EMC shall be provided a medical screening and, when necessary, stabilizing treatment, within the capabilities of the hospital.
- A MSE consisted of whatever forms of evaluation were required to reasonably determine whether or not an EMC exists.
- A person presenting with expressions of suicidal (SI, thoughts of causing one's own death) or homicidal (HI, thoughts or attempts to cause another's death) thoughts or determined dangerous to self or others, is considered to have an EMC.

Review of the hospital's policy titled, "Guidelines for Care of the Mental Health/Substance Abuse Patient," dated 07/2011, showed that if the patient presented with SI staff should contact social services or evaluate the patient using the Columbia-Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflict harm and desire to end one's life).

During a telephone interview on 10/05/20 at 1:58 PM, Staff U, Licensed Clinical Social Worker (LCSW), Social Services Senior Manager, stated that:
- If a patient presented with SI or HI, social services would be notified.
- The physicians and nurses always had social services complete the mental health assessment, even if they needed to keep the patient in the ED until morning when social services was on site.
- The nurses rarely completed the C-SSRS, social services would do this evaluation.
- Social services was on duty at the hospital or on-call 24 hours a day, seven days a week.
- An order for a social services consult was usually placed in the electronic medical record by a nurse, most commonly by the triage nurse.
- No patient was discharged until social services completed the mental health assessment.

Review of the social services on-call schedule showed that social services was available on 08/14/20.

Review of Patient #8's facesheet showed that the diagnosis was mental health examination (MHE)/fit for confinement (FIT, patient is medically and psychiatrically stable to go to jail) and the patient was disabled and had a guardian (a person appointed by a judge to take care of and manage the property and rights of a person who, because of age, understanding or self-control, is considered incapable of administering his or her own affairs).

During a telephone interview on 10/06/20 at 1:26 PM, Staff V, Admitting Clerk, stated that:
- She remembered Patient #8 very well, it was strange because it all happened so fast. The patient was there and then gone.
- The ED received a call from the police that they were transporting Patient #8 to the ED but she did not remember which nurse took the call.
- She did a quick registration to give the patient an account number, when she noticed the patient had a guardian. When a patient had a guardian, the responsibility of the registration staff was to place a green sticker on the patient's armband and follow-up with the nurse to ensure the consent for treatment form was signed by the guardian.
- She printed Patient #8's medical record information sheet (facesheet), the consent for treatment form and the armband. She placed the green sticker on the armband.
- She placed Patient #8's medical record facesheet, consent for treatment form and the armband on a clipboard; and placed it on the counter for the nurse.
- She did not know what happened to the clipboard and paperwork.
- Staff G, Registered Nurse (RN), ED Unit Coordinator, informed her to change the patient from a MHE to a FIT in the medical record, and that the patient was not receiving any emergency room (ER) services because Patient #8 refused to cooperate.

Review of the hospital's video surveillance of the ED ambulance garage and the ED west nurses' station, dated 08/14/20, from approximately 8:07 PM through approximately 8:16 PM, showed that:
- Staff G, RN, ED Unit Coordinator, waited for the police to arrive in the ambulance bay.
- Law Enforcement Officer (LEO) M, escorted handcuffed Patient #8 into a treatment room in the ED.
- LEO M turned towards Staff I, ED Physician; Staff J, RN, ED Triage/primary nurse; and Staff G, RN, ED Unit Coordinator for approximately one minute and 20 seconds, as two hospital security officers stood by.
- Staff I, ED Physician, left the area and went to sit at a desk and LEO M continued to stand towards Staff J, RN, ED Triage/primary nurse and Staff G, RN, ED Unit Coordinator, for another minute and 33 seconds.
- Staff G, RN ED Unit Coordinator, then escorted LEO M down to the end of the hall.
- Staff G stood with LEO M until LEO M left with Patient #8.
- LEO M returned to Patient #8's room, and escorted handcuffed Patient #8 out of the room and to the patrol car in the ambulance bay.
- The triage nurse was in Patient #8's room for less than 20 seconds total.
- The physician was in Patient #8's room for less than a minute and a half.
- The duration of the visit to the ED was less than 10 minutes.

During a telephone interview on 09/09/20 at 12:24 PM and 10/07/20 at 12:06 PM, LEO M stated that:
- He told the physician and Staff G, RN, ED Unit Coordinator, that Patient #8 had HI, he threatened to kill his parents, he was having random outbursts, and that he was saying he wanted to "kill police officers" and that he "sees dead bodies."
- He was taken aside by Staff G, RN, ED Unit Coordinator, where she informed him to put the patient back in his car and take him to Hospital B (hospital with inpatient psychiatric services) because Hospital A was not keeping the patient.
- He told Staff G, RN, ED Unit Coordinator, the mother was Patient #8's guardian, and that Patient #8 threatened to kill her and was acting psychotic (false beliefs or seeing/hearting/smelling/feeling things that are not there occurring in the absence of insight into their nature).
- Staff I, ED Physician, told him they could not keep Patient #8.
- He did not understand why the hospital would not admit Patient #8, like they have done before.
- He took Patient #8 to the police department, called a judge, got the paperwork for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), and LEO P, transported Patient #8 to Hospital B, as directed in the judge's order.

Review of Patient #8's ED record showed that:
- Staff I, ED Physician, documented Patient #8 was taken to the ED by police for aggressive behavior (behaviors that cause psychological or physical harm to another individual) and that the police reported the patient displayed aggressive behavior at home.
- Staff I, ED Physician, documented that Patient #8 reported he was not SI, not HI, and was not acutely psychotic.
- Staff I documented he had a lengthy discussion with the police officer, and advised the officer that Staff I had no reason to hold the patient in the ED as Patient #8 had no acute psychiatric (relating to mental illness) illness.
- Staff I documented that there was no pertinent past medical history.
- Patient #8 was discharged into police custody with the diagnosis of aggressive behavior.
- The patient was stable and any medical condition was stabilized.
- There was no documentation that the police officer informed Staff I, ED Physician, and Staff J, RN, ED Triage/primary nurse, that Patient #8 was SI and HI.
- There was no documentation by Staff I or Staff J that the patient had a guardian.
- There was no documentation by Staff J that social services was consulted or that a C-SSRS was completed.
- There was no social services mental health assessment documented.
- There was no assessment of current medications or if Patient #8 was compliant with his prescribed medications.
- There was no documentation that Staff I reviewed the previous ED record.
- No discharge education or documentation was included in the record.

Review of Patient #8's previous medical record dated 05/10/20, showed that the patient was disabled, developmentally delayed, had several suicide attempts in the past, had a history of aggression, Aspergers (a developmental disorder related to autism and characterized by higher than average intellectual ability coupled with impaired social skills and restrictive, repetitive patterns of interest and activities), and schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real).

During a telephone interview on 09/08/20 at 4:15 PM, Staff G, RN, ED Unit Coordinator, stated that LEO M informed hospital staff that Patient #8 was SI with HI.

During a telephone interview on 09/09/20 at 9:05 AM, and on 10/06/20 at 11:06 AM. Staff I, ED Physician, stated that:
- Patient #8 presented to the ED in handcuffs, with LEO M, who reported he wanted Patient #8 to have a MHE because the patient was verbally aggressive and had an altercation at home.
- He did not ask the police officer for any specific information related to the event.
- He assumed the patient was under arrest because Patient #8 had handcuffs on.
- He did not have social services see the patient because the patient did not want to stay, and the patient said he was not SI or HI.
- There was no reason to ask to speak to the family because Patient #8 was 20 years old.
- He did not ask Patient #8, the police officer, or staff members if this patient had a guardian.
- He was able to do a complete MSE to include a mental health assessment in less than a minute and a half.
- He did not review the previous medical record for Patient #8.
- No other staff member informed him of the previous patient visit where he was violent and required chemical and physical restraints.
- He informed LEO M, that Patient #8 did not want to be in the hospital, the patient was calm, alert and oriented, and that he had no legal reason to hold the patient.
- He thought LEO M, was going to go get a 96-hour hold, but did not know where Patient #8 was going to be taken after the hold was obtained.

During a telephone interview on 09/09/20 at 9:10 AM, and on 10/06/20 at 1:00 PM, Staff J, RN, stated that:
- She was the triage nurse and primary nurse for this patient (#8).
- Patient #8 sat on the end of the bed and was uncooperative because he would not answer any of her questions and the patient stated he did not know why he was in the ED.
- She did not complete the C-SSRS or consult social services because the patient was calm and "super cooperative."
- She did not know the patient had a guardian, registration did not tell her, and she did not ask the patient.
- The ED staff could complete the paperwork for a 96-hour hold if they believed patients were a danger to themselves or others, but they would have to be directed by the ED physician to do so.
- Patient #8 was in the custody of law enforcement, and she would not have talked to a guardian unless they had presented a legal document showing they were the patient's guardian.
- She did not recall seeing Patient #8's facesheet or consent for treatment form.
- She did not recall if she gave discharge documents to the patient or to the police officer.
- The patient was discharged to police custody.

Review of the paperwork provided by Hospital B for 96-hour detention, dated 08/14/20, showed that the court accepted the application submitted by LEO M because it was believed that Patient #8 had a mental disorder and presented a likelihood of serious harm to himself or others.

The hospital failed to provide a complete MSE for Patient #8. This failure had the potential to affect all patients who presented to the ED for a MSE.




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