HospitalInspections.org

1. Based on policy review, Medical Staff Rules and Regulations, medical record review, and interview, the hospital failed to ensure the dedicated emergency department (DED) provided an appropriate medical screening examination, within the capabilities of the hospital DED to determine if a psychiatric emergency medical condition existed for 1 of 23 (Patient #5) sampled patients.

Refer to 2406

2. Based on policy review, Medical Staff Rules and Regulations, medical record review, and interview, the hospital failed to ensure all patients presenting to the DED with psychiatric conditions were stabilized within the capabilities of the hospital or were appropriately transferred to another medical facility for 1 of 23 (Patient #5) sampled patients.

Refer to 2407

Based on policy review, review of Rules and Regulations of the Medical Staff, medical record review and interview, the hospital failed to ensure all patients presenting to the dedicated emergency department (DED) received an appropriate medical screening examination (MSE) within the capabilities of the hospital to determine if a psychiatric medical emergency existed for 1 of 23 (Patient #5) sampled patients. Failure to do so resulted in and IMMEDIATE AND SERIOUS threat to all patients presenting to the DED.


The findings included:

1. Review of the hospital's policy, "EMTALA, Definitions and Terminology" revealed, "...6. 'Emergency Medical Condition' means:...c. Psychiatric patients or those with symptoms of substance abuse may meet the definition of having an "Emergency medical Condition" as the absence of medical treatment may place his/her health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ; likewise, an individual expressing suicidal or homicidal thoughts or gestures, if dangerous to self or others, would be considered to have an 'Emergency Medical Condition'..."

Review of the hospital's policy "EMTALA- Medical Screening Examinations" revealed, "....POLICY..All individuals presenting to the Hospital Emergency department ("ED") or other Hospital property requesting examination or treatment are entitled to receive an appropriate Medical Screening Examination ("MSE") performed by qualified individuals to determine whether or not an Emergency Medical Condition exists...PROCEDURE:...Medical Screening Examination Requirement...Any individual presenting to the ED or other Hospital property and requesting care will receive an MSE within the capabilities of the Hospital's ED to determine whether or not an Emergency Medical Condition exists. These capabilities included the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and ED..."

Review of the hospital's "RULES AND REGULATIONS OF THE MEDICAL STAFF, ARTICLE 5 EMERGENCY DEPARTMENT SERVICES/PROCEDURES" revealed, "...1. Medical Screening Examination. If an individual comes to the emergency department of the Hospital and requests examination or treatment, the emergency department will perform, or will call the medical staff member on the unassigned call roster to perform a medical screening examination to determine whether an emergency medical condition exists...All medical screening examinations will be performed by Physicians or RN's [Registered Nurses] in Labor and Delivery, NP's [Nurse Practitioners] or PA's [Physician Assistants], working under medical protocols approved by the Medical Executive Committee...Medical Screening Examinations will be performed in a uniform, non-discriminatory manner and will generally consist of the following (although medical screening examinations may vary according to the condition and past history of the subject patient): a. Brief medical history; b. Documentation of vital signs; c. Visual examination of the injury, if possible; d. Medical assessment performed by a physican/oral surgeon, or RN in Labor and Delivery, NP or PA working under medical protocols approved by Medical Executive Committee...2. Emergency Medical Condition Defined. An emergency medical condition will generally exist where the condition is manifested by acute symptoms of sufficient severity that the absence of medical attention could reasonably be expected to result in:(i) placing the health of the individual....in serious jeopardy, (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part..."

Review of the hospital's policy "Plan for Provision of Behavioral Health or Substance Abuse Services", revealed, "POLICY: Patients who are emotionally ill or who suffer the results of alcoholism or drug abuse will be provided care with stabilizing treatment, evaluation, and referral when indicated...Identification and Assessment...Psychiatric Screening in the Emergency Department [DED]: When patients present with psychiatric, drug or alcohol related complaints to the ED, a psychiatric screen is then performed by qualified medical provider (QMP--ED physician, physician assistant [PA] or Nurse Practitioner [NP] by documenting on the appropriate ER [DED] note. After the psychiatric screening is completed, the [named Hospital #2] mobile crisis team...will be consulted..."


2. Review of an Emergency Medical Service (EMS) run ticket for Patient #5 dated 11/23/16 at 4:19 PM revealed, "DISPATCHED TO Patient UNKNOWN POSS [possible] KNIFE IN CHEST. PAST HISTORY NONE Patient POSS SELF INFLECTED [inflicted] KNIFE WOUND TO LEFT CHEST KNIFE WAS NOT IN CHEST CAVITY JUST UNDER SKIN WITH TEE SHIRT IN WOUND, CUT SHIRT AWAY FROM KNIFE. 45 Y/O [year old] B/M [black male] IN FLOOR AT HOME WITH KNIFE IN HIS CHEST NO BLEEDING AND GOOD BREATH SOUNDS, Patient STATED HE TRIED TO KILL HIMSELF BUT IT HUT [hurt] TOO BAD. Patient STOOD FROM SMALL BEDROOM TO HALLWAY PLACED ON COT AND INTO AMB [ambulance] WITH KNIFE STILL IN HIM. VITALSD [vital signs] NOTED ...IV [intravenous] IN LEFT ARM AND EMERGENCY TRANSPORT TO [Hospital #1] REPORT TO STAFF IN T3 [trauma room 3]..."

3. Review of Hospital #1's DED record for Patient #5 documented the patient presented to the DED on 11/23/16 via ambulance at 4:36 PM with a self inflicted stab wound to the chest. The triage nurse General Assessment at 4:43 PM ,documented, "...Psych [psychiatric] concerns: No...". The Triage Nurse Psych Assessment at 4:43 PM, documented, "Suicidal Ideation: Constant with plan Suicidal Safety Measures: Sitter at bedside..." The triage nurse assessment was inconsistent regarding psychiatric concerns.

DED physician #1 performed an a MSE at 4:38 PM and documented, "The patient presents with a stab wound. The onset was just prior to arrival. Location: Left chest. The location where the incident occurred as at home. The degree of bleeding minimal. Patient presents with a self inflicted stab wound to the chest, in suicide attempt. He used a large kitchen knife. He denies concommitant [concomitant] ingestion or injuries. No prior suicide attempts. No dyspnea, nausea, or vomiting...alcohol use denies...drug use denies...cooperative, flat affect..."

The Computerized Tomography (CT) results of the Thorax documented, "FINDINGS: A 24 cm [centimeter] blade. The finding enters the subcutaneous fat of the left anterior chest wall lateral to the left sternum anterior to the left 3rd rib, extends inferiorly and laterally within the subcutaneous fat, terminating anterior to the left 5th rib again within the subcutaneous fat The deep margin of this does abut the anterior aspect of the pectoralis muscle. Small amount of air has infiltrated into the pectoralis muscle...IMPRESSION 1. The knife is lodged in the subcutaneous fat of the left anterior chest wall. The deep margin of this abuts but does not penetrate the pectoralis muscle. 2. Specifically the finding does not cross the ribcage and there is no intrathoracic involvement or evidence of intrathoracic injury..."

Results of an urine drug screen at 6:17 PM revealed Patient #5 was positive for marijuana.

At 7:09 PM DED Physician #1 documented, "Procedure- Using slow constant tension the knife was removed. No significant bleeding noted...Description/repair Laceration 2 cm in length. Shape: flat depth: subcutaneous Details: clean Anesthesia: 6 ml [milliliter] 1% lidocane, with epinephrine..." The wound was closed with 3 sutures.

Mobile Crisis was contacted to perform a psychiatric assessment on Patient #5. There was no documentation of a Psychiatric screen completed by the DED Physician or other QMP per hospital policy.

4. Review of Hospital #2's Mobile Crisis documentation revealed Crisis Clinician #1 was dispatched at 6:50 PM and arrived at Hospital #1's DED at 7:45 PM. Crisis Clinician #1 performed a face to face assessment with Patient #5. The Crisis Clinician documented, "...Patient presents at [the name of Hospital #1] as a 45 year old SBM [single black male]. Patient was brought to the ER [emergency room/DED] with a self inflicted knife wound. Patient stated that he was not trying to kill himself. Patient stated that he had a passing thought of hurting himself. Patient stated that he does not want to die. Patient stated that he is stressed because he cannot find a job".
The Crisis Clinician further documented Patient #5 "denied any psychosis." The primary problem identified by Crisis Clinician #1 was "Suicidal Ideation (not active)".
Under the section on the assessment for Precipitating factors/Stressors identified the Crisis Clinician documented, "Patient is unemployed...". When the Crisis Clinician asked Patient #5, "Have you wished you were dead or wished you could sleep and not wake up in the past month?" Patient #5 responded "yes".
When the Crisis Clinician asked the patient, "Have you actually had any thoughts of killing yourself", the patient responded "No".
The Crisis Clinician documented the patient's Clinical Status as, "Agitation or Severe Anxiety, Major Depression Episode and Substance Abuse/Dependence"
The crisis counselor did not identify any protective factors during his assessment. The patient denied any homicidal or threatening behaviors during the crisis assessment. The patient reported using alcohol daily and to smoking marijuana 1-2 times in the past week.
The crisis counselor documented patient #5's appearance was disheveled, his speech was pressured, his affect was anxious, his thought process was coherent, his thought content was unremarkable, his behavior was cooperative, and his orientation was to person, place, situation and time.
The Diagnostic and Statistical Manual of Mental Disorders 5th edition diagnosis documented by Crisis Clinician #1 was Severe Major depressive disorder, single episode. The severity was documented as "with anxious distress (moderate)"
The patient refused Hospital #2's Crisis Stabilization Unit (a voluntary program) and a safety plan (also known as Crisis Management Plan) was established with the patient. The justification for the safety plan was documented as, "Patient stated that he was not trying to kill himself. Patient stated he had no more thoughts of hurting himself. The doctor stated that he was okay to go home."

Review of the Crisis Management Plan developed by Crisis Clinician #1 and Patient #5 dated 11/23/16 documented, "Triggers: PATIENT WAS BROUGHT TO THE ER [DED] WITH A SELF-INFLICTED KNIFE WOUND. PATIENT STATED THAT HE WAS STRESSED BECAUSE HE COULD NOT FIND A JOB. PATIENT STATED THAT HE WAS NOT TRYING TO KILL HIMSELF. Warning Signs: PATIENT WAS DRINKING AT THE TIME. PATIENT STATED THAT HE JUST HAD A FLEETING THOUGHT OF HURTING HIMSELF. What to do/Coping: PATIENT WAS GIVEN INFORMATION TO SET UP AN OUTPATIENT COUNSELING APPOINTMENT. PATIENT LIVES WITH GIRLFRIEND AND SHE WILL WATCH PATIENT. What NOT to do/ Techniques to avoid: SELF HARM. The support system was identified as the Patient's Mother. Her name and telephone number was listed on the Crisis Management Plan. There was no evidence the girlfriend or mother was contacted by the crisis counselor to discuss the plan. The patient signed the plan at 8:11 PM. The plan included Hospital #2's crisis hotline and the Statewide Crisis hotline.

5. DED Physican #1 at Hospital #1 documented [Name of Hospital #2] Crisis Clinician recommendations for Patient #5 were the patient had signed a Safety contract and was safe to discharge home with a referral for outpatient counseling.

Patient #5 was discharged home from the DED on 11/23/16 at 9:00 PM and given written information on Laceration care. He was instructed to follow up with the DED or a primary care physician for suture removal. There was no written educational material regarding self harm, suicide attempts or Major Depression provided by the DED upon discharge. There was no documentation of counseling provided to the patient for major depression/anxiety. There was no other documentation of psychiatric interventions for Patient #5.

6. During an interview in the conference room on 12/6/16 at 3:20 PM, the Director of Hospital #2 stated a suicide attempt in itself would not warrant an involuntary admission to a psychiatric facility. She stated her Crisis Clinicians had to follow the law and the criteria set forth for involuntary admissions. She stated her clinical staff encourage patients to enter their voluntary unit the Crisis Stabilization Unit (CSU). If a patient refuses the CSU and they verbalize they no longer wish to harm themselves or others, other factors are considered such as a supportive family (there was no documentation the patient's family had received any information and/or communication from the hospitals), and a safety plan may be developed. She stated if a patient is committed, who does not meet the criteria, they are violating the patient's rights. She stated each case is decided based on a clinician's professional judgement after the crisis assessment is completed.


7. During an interview in the conference room with EMS Paramedic #1 and #2 on 12/7/16 at 10:20 AM, they both verified they were dispatched to a residence related to a self inflicted stab wound for Patient #5. Both EMS Paramedic #1 and #2 stated the knife was inserted downward, superficially behind the nipple area at 45 degrees. EMS Paramedic #2 stated, "When he [Patient #5] stood up his chin almost touched the handle [of knife]. EMS Paramedic #1 described the knife as similar to a steak knife. EMS paramedic #2 stated during EMS transport to Hospital #1's DED, Patient #5 stated he wanted to kill himself but it [self inflicted knife injury] hurt too bad.

8. During an interview in the conference room on 12/7/16 at 12:35 PM, the Director of Systems Accreditation stated there was no additional training for DED medical staff regarding suicidal/ homicidal patients or patients with psychiatric needs, the medical staff followed their medical training. During a subsequent interview on 12/7/16 at 2:25 PM, she stated Physician Assistants received training in a psychiatric rotation during their core curriculum and Nurse Practitioners (NP) receive a psychiatric rotation in their RN core curriculum. She verified the mid level practitioners in the DED did not receive any additional psychiatric training provided by the hospital.

9. During an interview in the conference room at Hospital #1 with DED Physician #1 on 12/8/16 at 10:45 AM, she stated Patient #5 presented to the DED on 11/23/16 with a superficial self-inflicted stab wound to the chest. She stated about 4 inches of the knife was in the skin but it was very superficial. She verified chest X rays and a CT scan were performed to verify there was no penetration into the thoracic cavity. She stated labwork was obtained, the knife was removed, the wound was sutured, he was deemed medically stable and [named Hospital #2 Crisis team] was consulted.
When asked about Patient #5's mental status, DED Physician #1 stated he initially had a flat affect, initially quiet, he answered questions appropriately and later opened up more. She stated he reported he wanted to hurt himself, but not kill himself. She further stated the patient reported he had never done anything like this before. When asked if he was psychotic, DED Physician #1 stated, "I don't know if he was psychotic or not...that area of expertise is mental health providers". DED Physician #1 again stated, "He was trying to hurt himself, but not kill himself." She stated that once she knew the patient was medically stable, she consulted [Hospital #2 for a psychiatric assessment]. She stated the mental health provider [Hospital #2] makes the recommendation regarding discharge. She stated, "The decision is ultimately up to the mental health provider." When asked who initiated the discharge orders, she stated, "...the discharge order is mine, the discharge disposition final decision is the mental health provider...the disposition is not my final decision."
When asked what led her to the decision that Patient #5 was medically stable for discharge, DED Physician #1 stated, "I don't have the expertise, I defer to them [Hospital #2 Crisis Staff] to make that decision." When asked what criteria are required for an involuntary admission to a psychiatric facility, she stated, "Mental Health Specialist [Hospital #2 Crisis Staff] determine that, I'm not aware of the criteria...they are experts, we confer. I complete the form after talking with [the name of Hospital #2 Crisis Staff]."

10. During an interview in the conference room at Hospital #1 on 12/8/16 at 1:03 PM, Crisis Clinician #1 was asked what he recalled about his assessment of Patient #5 on 11/23/16. He stated the patient came to the DED at Hospital #1 with a self -inflicted knife wound to the chest, a piercing type wound. He stated he discussed the patient with DED Physician #1 who stated the patient denied a suicide attempt. He stated when he met with Patient #5, he denied the act was a suicide attempt. He stated the patient reported he was under a lot of stress because he had lost his job and he just wanted to feel something. He stated he attempted to reach Patient #5's mother, who was listed as his emergency contact in the DED record, but he was unable to reach her. He stated the patient's girlfriend was not in the DED and he did not speak to her. He stated that he discussed the case with DED Physican #1 and they agreed the patient was not a threat to himself or others. He described Patient #5's affect as flat, behavior as cooperative and stated he was respectful when answering questions.
He stated the patient was not responding to outside stimuli and denied hearing things. When asked about how the safety plan was developed, Crisis Clinician #1 stated, "The patient said he lived with his girlfriend and she would watch him." He verified he was not given a telephone number by Patient #5 to reach his girlfriend. He stated Patient #5 said he did not have her telephone number because it was saved in his cell phone and he did not have his cell phone with him in the DED.
When asked how he made the determination to send the patient home with outpatient follow-up, he stated, "Based on what he was saying and what he told the doctor." He stated the patient refused the CSU. He stated the patient said he had a little nervous breakdown and wanted to go home. He stated he and DED Physician #1 agreed he did not meet the requirements for commitment and the only other option was safety plan.
When asked what the criteria were for commitment, he stated, "basically if we feel he is a threat to self or others, so psychotic that he can't function...we follow the guidelines...self harm does not mean you are suicidal..." He verified he was not able to identify any protective factors during his assessment of Patient #5. When asked who makes the final determination about the disposition of a patient with identified psychiatric needs, he stated, "Its a joint decision but ultimately the doctor has to sign the commitment..."

11. During an interview in the conference room at Hospital #1 on 12/18/16 at 2:40 PM, the Medical Director of the DED stated that when a patient presented to the DED with psychiatric problems a MSE would be conducted just like for any other patient. He stated, "Once medically cleared, we contact [Hospital #2 Crisis staff]. He stated that once Hospital #2's crisis staff complete the crisis assessment and make a recommendation, they decide together what to do. He again stated we medically clear them before Hospital #2 is called. He stated, "We rely on their [staff from Hospital #2] expertise, obviously they are a patient in our ER [DED]...we follow their recommendation [Hospital #2's crisis staff]..." He further stated the decision is a collaborative effort of both providers. He stated, "We rely on them to do the Psychiatric evaluation we are just there for the medical aspect of it..."

12. During an interview in the conference room on 12/8/16 at 2:45 PM, the Director of Hospital #2 stated when determining if a patient is safe to discharge home from the DED, Protective factors (which were not identified) and Risk factors play a big role in the Crisis Clinician's assessment. She stated any previous attempts of suicide would also be considered. When asked if it was appropriate to develop a safety plan without family or support system present, she stated, " it could be if they have protective factors...yes, may have no family involved..."


13. During a telephone interview on 12/12/16 at 12:25 PM, DED Technician #1 stated she was assigned to sit with Patient #5 during his DED visit on 11/23/16, due to his suspected suicide attempt. She stated the patient was cooperative and quiet. She stated he would sit up from the stretcher and the knife would dangle from his chest, but when she asked him to lie back down he cooperated. She stated he verbalized no pain, despite he had a knife wound to his chest. She stated he never verbalized pain, even when the knife was removed and the physican repaired the wound.


14. Review of the medical record from Hospital #2 for Patient #5 revealed on 11/24/16 at approximately 10:00 AM, Patient #5 presented to Hospital #2's triage area for voluntary admission to the CSU accompanied by his father.
A triage screening was conducted by Psychiatric Technician #1. The screening documented, "pt [patient] has a self inflicted stab wound to his chest. (pt was seen in the ER [Hospital #1's DED] last night and was cleared medically) pt says he did that last night to stop the voices he has been hearing. pt says he has been seeing and hearing voices. pt says this started a few months ago...pt denies having suicidal thoughts currently but he did stab himself yesterday in order to stop the voices he was having..." The patient denied a history of mental illness. He reported using cocaine, marijuana and drinking alcohol daily. The patients emergency contact listed was his father. The patient reported a history of high blood pressure. A urine drug screen was performed with results reported at 11:18 AM revealed the patient tested positive for marijuana and cocaine. The triage assessment was electronically signed by Psychiatric Technician #1 at 11:19 AM.

The Crisis Clinician #2 at Hospital #2 documented the following at 11:50 AM, "Pt is a 45 BM [black male] presenting at [Hospital #2] triage with his father requesting help. Pt reports poor appetite and poor sleep. Pt reports hearing voices for the past few months telling him to harm himself. Pt reports 4 (24 ounces) of beer daily since he was 15 or 16. Pt reports THC [tetrahydrocannabinol/marijuana] dime sack daily since age 15 or 16. Pt denies HI [homicidal ideation] Pt reports SI [Suicidal Ideation] due to hearing voices. Pt reports voices tell him to harm self at times. Pt stabbed self last night due to voices. Pt reports limited support system. Pt reports increased paranoia. Pt reports he has never had treatment. Pt reports increased depression and anxiety, and per pt's father has been walking the street all night. Pt denies any withdrawal symptoms at this time."

During an interview in the conference room on 12/8/16 at 3:05 PM Crisis Clinician #2 stated she saw Patient #5 at Hospital #2 on 11/24/16 after the triage was completed by Psychiatric Technician #1. She stated she reviewed Crisis Clinician #1's documentaion from the night before (11/23/16) when he was seen in the Hospital #1's DED. When asked to explain his demeanor/behavior on 11/24/16, Crisis Clinician #2 stated he was preoccupied and admitted he was hearing voices but he displayed no aggression. She stated she left the triage area after she had performed her assessment. Patient #5 and his father were in the Triage waiting area. Psychiatric Technician #1 remained in the triage area.

15. Review of the local newspaper reported the following story on 11/24/16 at 7:01 PM, "[Hospital #2] stabbing suspect [Patient #5] dies...A medical professional [Psychiatric Technician #1] was stabbed, and suspect was later fatally shot by [police officer] early Thursday afternoon at the [Hospital #2]...according to the Tennessee Bureau of Investigation [TBI]...According to an email from TBI...[Patient #5], 45 [years old] was being treated at [Hospital #2] and stabbed an employee with a knife around 12:45 PM Thursday...Two officers... initially responded to the scene, where, during an exchange with [Patient #5], the situation escalated and resulted in at least one of the officers firing his weapon, striking the subject, who later died at [Hospital #1]...According to email, the employee is undergoing treatment at [the name of another hospital]..."


16. Review of the EMS record dated 11/24/16 for Patient #5 revealed the patient was transported via EMS and arrived at Hospital #1's DED on 11/24/16 at 1:11 PM. A MSE performed at 1:11 PM documented the patient presented with a gunshot wound to the left anterior chest with onset just prior to arrival. DED physician #2 documented the character of injury was long range and the incident occurred in the street. The patient was in severe distress with no pulse or respiratory effort.
The physician documented, "...a gunshot wound to the mid thoracic back with no exit wound. has bilateral bs [breath sounds] with bagging [manual Ambu bag]". The patient had no pulse. DED physician #2 performed an emergent left thoracotomy at the 5th intercostal space and found a large quantity of clotted and unclotted blood. The DED physician documented the heart was flaccid and the physican could palpate a large hole in the posterior wall of the heart. Resuscitation efforts were stopped and Patient #5 expired on 11/24/16 at 1:16 PM. The cause of death was "GSW [gunshot wound]".


17. An email from the TBI Assistant Special Agent in Charge sent to this office verified the following information via email on 12/13/16 at 2:43 PM: "... Both officers involved in the shooting are employees of the [local police department] and the names have not been released...On the date of the incident (11/24/16), one involved officer was assigned to [working in Hospital #1's] DED and the second officer responded from a patrol unit...The investigation is still active and ongoing with the TBI". No further information could be gathered at this time.

Based on policy review, review of Rules and Regulations of the Medical Staff, medical record review and interview, the hospital failed to ensure all patients presenting to the dedicated emergency department (DED) with psychiatric conditions were stabilized within the capabilities of the hospital or appropriate transferred to another medical facility for 1 of 23 (Patient #5) sampled patients. Failure to do so resulted in and IMMEDIATE AND SERIOUS threat to all patients presenting to the DED.


The findings included:

1. Review of the hospital's policy "EMTALA, Stabilization and Transfer" revealed, "...Patients found to have an emergency medical condition will be provided with stabilizing treatment within the scope of the Hospital's capabilities before being transferred or discharged. Patient transfers will be performed according to procedures and within guidelines of EMTALA..Stabilization: 1. A patient is deemed to have been stabilized when the treating physician attending the patient in the Emergency Department (ED) determines within reasonable clinical confidence that the emergency medical condition has resolved...2. Once stabilized, the basis for the determination of stabilization should be documented in the patient's medical record...d. For patients with psychiatric conditions, the patient is considered stable when the physician treatment the patient has determined that the patient is no longer a threat to himself /herself or others..."

Review of the hospital's policy "EMTALA, Definitions and Terminology" revealed, "...'Stabilized' or 'to stabilize' means resolution of the Emergency Medical Condition such that the patient's condition is one where no material deterioration is likely, within reasonable medical probability, to occur during or result from the transfer/discharge of the patient...'Stable for Discharge' means that after providing a Medical Screening Examination and stabilizing treatment, the Hospital may discharge a patient if the treating physician has determined, within reasonable clinical confidence, that the patient has reached the point where his/her continued care (including diagnostic work up and treatment) could be reasonably performed as an outpatient or at a later time as an inpatient, provided that the patient is provided an appropriate plan for follow-up care and discharge instructions..."


Review of the hospital's policy "Plan for Provision of Behavioral Health or Substance Abuse Services", revealed, "POLICY: Patients who are emotionally ill or who suffer the results of alcoholism or drug abuse will be provided care with stabilizing treatment, evaluation, and referral when indicated...Identification and Assessment...Psychiatric Screening in the Emergency Department [DED]: When patients present with psychiatric, drug or alcohol related complaints to the ED, a psychiatric screen is then performed by qualified medical provider (QMP--ED physician, physician assistant [PA] or Nurse Practitioner [NP] by documenting on the appropriate ER [DED] note. After the psychiatric screening is completed, the [named Hospital #2] mobile crisis team...will be consulted..."

Review of the hospital's RULES AND REGULATIONS OF THE MEDICAL STAFF, ARTICLE 5 EMERGENCY DEPARTMENT SERVICES/PROCEDURES" revealed, "MEDICAL SCREENING AND TRANSFER REQUIREMENTS...4. Where the medical Screening Exam Reveals and Emergency Medical Condition. If the medical screening examination reveals the existence of an emergency medical condition, the treating physician will either provide further treatment in order to stabilize the condition prior to transferring the patient or the patient will be appropriately transferred.

2. Review of an Emergency Medical Service (EMS) run ticket for Patient #5 dated 11/23/16 at 4:19 PM revealed, "DISPATCHED TO Patient UNKNOWN POSS [possible] KNIFE IN CHEST. PAST HISTORY NONE Patient POSS SELF INFLECTED [inflicted] KNIFE WOUND TO LEFT CHEST KNIFE WAS NOT IN CHEST CAVITY JUST UNDER SKIN WITH TEE SHIRT IN WOUND, CUT SHIRT AWAY FROM KNIFE. 45 Y/O [year old] B/M [black male] IN FLOOR AT HOME WITH KNIFE IN HIS CHEST NO BLEEDING AND GOOD BREATH SOUNDS, Patient STATED HE TRIED TO KILL HIMSELF BUT IT HUT [hurt] TOO BAD. Patient STOOD FROM SMALL BEDROOM TO HALLWAY PLACED ON COT AND INTO AMB [ambulance] WITH KNIFE STILL IN HIM. VITALSD [vital signs] NOTED ...IV [intravenous] IN LEFT ARM AND EMERGENCY TRANSPORT TO [Hospital #1] REPORT TO STAFF IN T3 [trauma room 3]..."

3. Review of Hospital #1's DED record for Patient #5 documented the patient presented to the DED on 11/23/16 via ambulance at 4:36 PM with a self inflicted stab wound to the chest. The triage nurse General Assessment at 4:43 PM ,documented, "...Psych [psychiatric] concerns: No...". The Triage Nurse Psych Assessment at 4:43 PM, documented, "Suicidal Ideation: Constant with plan Suicidal Safety Measures: Sitter at bedside..." The triage nurse assessment was inconsistent regarding psychiatric concerns.

DED physician #1 performed an a MSE at 4:38 PM and documented, "The patient presents with a stab wound. The onset was just prior to arrival. Location: Left chest. The location where the incident occurred as at home. The degree of bleeding minimal. Patient presents with a self inflicted stab wound to the chest, in suicide attempt. He used a large kitchen knife. He denies concommitant [concomitant] ingestion or injuries. No prior suicide attempts. No dyspnea, nausea, or vomiting...alcohol use denies...drug use denies...cooperative, flat affect..."

The Computerized Tomography (CT) results of the Thorax documented, "FINDINGS: A 24 cm [centimeter] blade. The finding enters the subcutaneous fat of the left anterior chest wall lateral to the left sternum anterior to the left 3rd rib, extends inferiorly and laterally within the subcutaneous fat, terminating anterior to the left 5th rib again within the subcutaneous fat The deep margin of this does abut the anterior aspect of the pectoralis muscle. Small amount of air has infiltrated into the pectoralis muscle...IMPRESSION 1. The knife is lodged in the subcutaneous fat of the left anterior chest wall. The deep margin of this abuts but does not penetrate the pectoralis muscle. 2. Specifically the finding does not cross the ribcage and there is no intrathoracic involvement or evidence of intrathoracic injury..."

Results of an urine drug screen at 6:17 PM revealed Patient #5 was positive for marijuana.

At 7:09 PM DED Physician #1 documented, "Procedure- Using slow constant tension the knife was removed. No significant bleeding noted...Description/repair Laceration 2 cm in length. Shape: flat depth: subcutaneous Details: clean Anesthesia: 6 ml [milliliter] 1% lidocane, with epinepherine..." The wound was closed with 3 sutures.

Mobile Crisis was contacted to perform a psychiatric assessment on Patient #5. There was no documentation of a Psychiatric screen completed by the DED Physician or other QMP per hospital policy.


4. Review of Hospital #2's Mobile Crisis documentation revealed Crisis Clinician #1 was dispatched at 6:50 PM and arrived at Hospital #1's DED at 7:45 PM. Crisis Clinician #1 performed a face to face assessment with Patient #5. The Crisis Clinician documented, "...Patient presents at [the name of Hospital #1] as a 45 year old SBM [single black male]. Patient was brought to the ER [emergency room/DED] with a self inflicted knife wound. Patient stated that he was not trying to kill himself. Patient stated that he had a passing thought of hurting himself. Patient stated that he does not want to die. Patient stated that he is stressed because he cannot find a job".
The Crisis Clinician further documented Patient #5 "denied any psychosis." The primary problem identified by Crisis Clinician #1 was "Suicidal Ideation (not active)".
Under the section on the assessment for Precipitating factors/Stressors identified the Crisis Clinician documented, "Patient is unemployed...". When the Crisis Clinician asked Patient #5, "Have you wished you were dead or wished you could sleep and not wake up in the past month?" Patient #5 responded "yes".
When the Crisis Clinician asked the patient, "Have you actually had any thoughts of killing yourself", the patient responded "No".
The Crisis Clinician documented the patient's Clinical Status as, "Agitation or Severe Anxiety, Major Depression Episode and Substance Abuse/Dependence"
The crisis counselor did not identify any protective factors during his assessment. The patient denied any homicidal or threatening behaviors during the crisis assessment. The patient reported using alcohol daily and to smoking marijuana 1-2 times in the past week.
The crisis counselor documented patient #5's appearance was disheveled, his speech was pressured, his affect was anxious, his thought process was coherent, his thought content was unremarkable, his behavior was cooperative, and his orientation was to person, place, situation and time.
The Diagnostic and Statistical Manual of Mental Disorders 5th edition diagnosis documented by Crisis Clinician #1 was Severe Major depressive disorder, single episode. The severity was documented as "with anxious distress (moderate)"
The patient refused Hospital #2's Crisis Stabilization Unit (a voluntary program) and a safety plan (also known as Crisis Management Plan) was established with the patient. The justification for the safety plan was documented as, "Patient stated that he was not trying to kill himself. Patient stated he had no more thoughts of hurting himself. The doctor stated that he was okay to go home."

Review of the Crisis Management Plan developed by Crisis Clinician #1 and Patient #5 dated 11/23/16 documented, "Triggers: PATIENT WAS BROUGHT TO THE ER [DED] WITH A SELF-INFLICTED KNIFE WOUND. PATIENT STATED THAT HE WAS STRESSED BECAUSE HE COULD NOT FIND A JOB. PATIENT STATED THAT HE WAS NOT TRYING TO KILL HIMSELF. Warning Signs: PATIENT WAS DRINKING AT THE TIME. PATIENT STATED THAT HE JUST HAD A FLEETING THOUGHT OF HURTING HIMSELF. What to do/Coping: PATIENT WAS GIVEN INFORMATION TO SET UP AN OUTPATIENT COUNSELING APPOINTMENT. PATIENT LIVES WITH GIRLFRIEND AND SHE WILL WATCH PATIENT. What NOT to do/ Techniques to avoid: SELF HARM. The support system was identified as the Patient's Mother. Her name and telephone number was listed on the Crisis Management Plan. There was no evidence the girlfriend or mother was contacted by the crisis counselor to discuss the plan. The patient signed the plan at 8:11 PM. The plan included Hospital #2's crisis hotline and the Statewide Crisis hotline.

5. DED Physican #1 at Hospital #1 documented [Name of Hospital #2] Crisis Clinician recommendations for Patient #5 were the patient had signed a Safety contract and was safe to discharge home with a referral for outpatient counseling.

Patient #5 was discharged home from the DED on 11/23/16 at 9:00 PM and given written information on Laceration care. He was instructed to follow up with the DED or a primary care physician for suture removal. There was no written educational material regarding self harm, suicide attempts or Major Depression provided by the DED upon discharge. There was no documentation of counseling provided to the patient for major depression/anxiety. There was no other documentation of psychiatric interventions for Patient #5.

6. During an interview in the conference room on 12/6/16 at 3:20 PM, the Director of Hospital #2 stated a suicide attempt in itself would not warrant an involuntary admission to a psychiatric facility. She stated her Crisis Clinicians had to follow the law and the criteria set forth for involuntary admissions. She stated her clinical staff encourage patients to enter their voluntary unit the Crisis Stabilization Unit (CSU). If a patient refuses the CSU and they verbalize they no longer wish to harm themselves or others, other factors are considered such as a supportive family (there was no documentation the patient's family had received any information and/or communication from the hospitals), and a safety plan may be developed. She stated if a patient is committed, who does not meet the criteria, they are violating the patient's rights. She stated each case is decided based on a clinician's professional judgement after the crisis assessment is completed.


7. During an interview in the conference room with EMS Paramedic #1 and #2 on 12/7/16 at 10:20 AM, they both verified they were dispatched to a residence related to a self inflicted stab wound for Patient #5. Both EMS Paramedic #1 and #2 stated the knife was inserted downward, superficially behind the nipple area at 45 degrees. EMS Paramedic #2 stated, "When he [Patient #5] stood up his chin almost touched the handle [of knife]. EMS Paramedic #1 described the knife as similar to a steak knife. EMS paramedic #2 stated during EMS transport to Hospital #1's DED, Patient #5 stated he wanted to kill himself but it [self inflicted knife injury] hurt too bad.

8. During an interview in the conference room on 12/7/16 at 12:35 PM, the Director of Systems Accreditation stated there was no additional training for DED medical staff regarding suicidal/ homicidal patients or patients with psychiatric needs, the medical staff followed their medical training. During a subsequent interview on 12/7/16 at 2:25 PM, she stated Physician Assistants received training in a psychiatric rotation during their core curriculum and Nurse Practitioners (NP) receive a psychiatric rotation in their RN core curriculum. She verified the mid level practitioners in the DED did not receive any additional psychiatric training provided by the hospital.

9. During an interview in the conference room at Hospital #1 with DED Physician #1 on 12/8/16 at 10:45 AM, she stated Patient #5 presented to the DED on 11/23/16 with a superficial self-inflicted stab wound to the chest. She stated about 4 inches of the knife was in the skin but it was very superficial. She verified chest X rays and a CT scan were performed to verify there was no penetration into the thoracic cavity. She stated labwork was obtained, the knife was removed, the wound was sutured, he was deemed medically stable and [named Hospital #2 Crisis team] was consulted.
When asked about Patient #5's mental status, DED Physician #1 stated he initially had a flat affect, initially quiet, he answered questions appropriately and later opened up more. She stated he reported he wanted to hurt himself, but not kill himself. She further stated the patient reported he had never done anything like this before. When asked if he was psychotic, DED Physician #1 stated, "I don't know if he was psychotic or not...that area of expertise is mental health providers". DED Physician #1 again stated, "He was trying to hurt himself, but not kill himself." She stated that once she knew the patient was medically stable, she consulted [Hospital #2 for a psychiatric assessment]. She stated the mental health provider [Hospital #2] makes the recommendation regarding discharge. She stated, "The decision is ultimately up to the mental health provider." When asked who initiated the discharge orders, she stated, "...the discharge order is mine, the discharge disposition final decision is the mental health provider...the disposition is not my final decision."
When asked what led her to the decision that Patient #5 was medically stable for discharge, DED Physician #1 stated, "I don't have the expertise, I defer to them [Hospital #2 Crisis Staff] to make that decision." When asked what criteria are required for an involuntary admission to a psychiatric facility, she stated, "Mental Health Specialist [Hospital #2 Crisis Staff] determine that, I'm not aware of the criteria...they are experts, we confer. I complete the form after talking with [the name of Hospital #2 Crisis Staff]."

10. During an interview in the conference room at Hospital #1 on 12/8/16 at 1:03 PM, Crisis Clinician #1 was asked what he recalled about his assessment of Patient #5 on 11/23/16. He stated the patient came to the DED at Hospital #1 with a self -inflicted knife wound to the chest, a piercing type wound. He stated he discussed the patient with DED Physician #1 who stated the patient denied a suicide attempt. He stated when he met with Patient #5, he denied the act was a suicide attempt. He stated the patient reported he was under a lot of stress because he had lost his job and he just wanted to feel something. He stated he attempted to reach Patient #5's mother, who was listed as his emergency contact in the DED record, but he was unable to reach her. He stated the patient's girlfriend was not in the DED and he did not speak to her. He stated that he discussed the case with DED Physican #1 and they agreed the patient was not a threat to himself or others. He described Patient #5's affect as flat, behavior as cooperative and stated he was respectful when answering questions.
He stated the patient was not responding to outside stimuli and denied hearing things. When asked about how the safety plan was developed, Crisis Clinician #1 stated, "The patient said he lived with his girlfriend and she would watch him." He verified he was not given a telephone number by Patient #5 to reach his girlfriend. He stated Patient #5 said he did not have her telephone number because it was saved in his cell phone and he did not have his cell phone with him in the DED.
When asked how he made the determination to send the patient home with outpatient follow-up, he stated, "Based on what he was saying and what he told the doctor." He stated the patient refused the CSU. He stated the patient said he had a little nervous breakdown and wanted to go home. He stated he and DED Physician #1 agreed he did not meet the requirements for commitment and the only other option was safety plan.
When asked what the criteria were for commitment, he stated, "basically if we feel he is a threat to self or others, so psychotic that he can't function...we follow the guidelines...self harm does not mean you are suicidal..." He verified he was not able to identify any protective factors during his assessment of Patient #5. When asked who makes the final determination about the disposition of a patient with identified psychiatric needs, he stated, "Its a joint decision but ultimately the doctor has to sign the commitment..."

11. During an interview in the conference room at Hospital #1 on 12/18/16 at 2:40 PM, the Medical Director of the DED stated that when a patient presented to the DED with psychiatric problems a MSE would be conducted just like for any other patient. He stated, "Once medically cleared, we contact [Hospital #2 Crisis staff]. He stated that once Hospital #2's crisis staff complete the crisis assessment and make a recommendation, they decide together what to do. He again stated we medically clear them before Hospital #2 is called. He stated, "We rely on their [staff from Hospital #2] expertise, obviously they are a patient in our ER [DED]...we follow their recommendation [Hospital #2's crisis staff]..." He further stated the decision is a collaborative effort of both providers. He stated, "We rely on them to do the Psychiatric evaluation we are just there for the medical aspect of it..."

12. During an interview in the conference room on 12/8/16 at 2:45 PM, the Director of Hospital #2 stated when determining if a patient is safe to discharge home from the DED, Protective factors (which were not identified) and Risk factors play a big role in the Crisis Clinician's assessment. She stated any previous attempts of suicide would also be considered. When asked if it was appropriate to develop a safety plan without family or support system present, she stated, " it could be if they have protective factors...yes, may have no family involved..."


13. During a telephone interview on 12/12/16 at 12:25 PM, DED Technician #1 stated she was assigned to sit with Patient #5 during his DED visit on 11/23/16, due to his suspected suicide attempt. She stated the patient was cooperative and quiet. She stated he would sit up from the stretcher and the knife would dangle from his chest, but when she asked him to lie back down he cooperated. She stated he verbalized no pain, despite he had a knife wound to his chest. She stated he never verbalized pain, even when the knife was removed and the physican repaired the wound.


14. Review of the medical record from Hospital #2 for Patient #5 revealed on 11/24/16 at approximately 10:00 AM, Patient #5 presented to Hospital #2's triage area for voluntary admission to the CSU accompanied by his father.
A triage screening was conducted by Psychiatric Technician #1. The screening documented, "pt [patient] has a self inflicted stab wound to his chest. (pt was seen in the ER [Hospital #1's DED] last night and was cleared medically) pt says he did that last night to stop the voices he has been hearing. pt says he has been seeing and hearing voices. pt says this started a few months ago...pt denies having suicidal thoughts currently but he did stab himself yesterday in order to stop the voices he was having..." The patient denied a history of mental illness. He reported using cocaine, marijuana and drinking alcohol daily. The patients emergency contact listed was his father. The patient reported a history of high blood pressure. A urine drug screen was performed with results reported at 11:18 AM revealed the patient tested positive for marijuana and cocaine. The triage assessment was electronically signed by Psychiatric Technician #1 at 11:19 AM.

The Crisis Clinician #2 at Hospital #2 documented the following at 11:50 AM, "Pt is a 45 BM [black male] presenting at [Hospital #2] triage with his father requesting help. Pt reports poor appetite and poor sleep. Pt reports hearing voices for the past few months telling him to harm himself. Pt reports 4 (24 ounces) of beer daily since he was 15 or 16. Pt reports THC [tetrahydrocannabinol/marijuana] dime sack daily since age 15 or 16. Pt denies HI [homicidal ideation] Pt reports SI [Suicidal Ideation] due to hearing voices. Pt reports voices tell him to harm self at times. Pt stabbed self last night due to voices. Pt reports limited support system. Pt reports increased paranoia. Pt reports he has never had treatment. Pt reports increased depression and anxiety, and per pt's father has been walking the street all night. Pt denies any withdrawal symptoms at this time."

During an interview in the conference room on 12/8/16 at 3:05 PM Crisis Clinician #2 stated she saw Patient #5 at Hospital #2 on 11/24/16 after the triage was completed by Psychiatric Technician #1. She stated she reviewed Crisis Clinician #1's documentaion from the night before (11/23/16) when he was seen in the Hospital #1's DED. When asked to explain his demeanor/behavior on 11/24/16, Crisis Clinician #2 stated he was preoccupied and admitted he was hearing voices but he displayed no aggression. She stated she left the triage area after she had performed her assessment. Patient #5 and his father were in the Triage waiting area. Psychiatric Technician #1 remained in the triage area.

15. Review of the local newspaper reported the following story on 11/24/16 at 7:01 PM, "[Hospital #2] stabbing suspect [Patient #5] dies...A medical professional [Psychiatric Technician #1] was stabbed, and suspect was later fatally shot by [police officer] early Thursday afternoon at the [Hospital #2]...according to the Tennessee Bureau of Investigation [TBI]...According to an email from TBI...[Patient #5], 45 [years old] was being treated at [Hospital #2] and stabbed an employee with a knife around 12:45 PM Thursday...Two officers... initially responded to the scene, where, during an exchange with [Patient #5], the situation escalated and resulted in at least one of the officers firing his weapon, striking the subject, who later died at [Hospital #1]...According to email, the employee is undergoing treatment at [the name of another hospital]..."


16. Review of the EMS record for Patient #5 revealed the patient was transported via EMS and arrived at Hospital #1's DED on 11/24/16 at 1:11 PM. A MSE performed at 1:11 PM documented the patient presented with a gunshot wound to the left anterior chest with onset just prior to arrival. DED physician #2 documented the character of injury was long range and the incident occurred in the street. The patient was in severe distress with no pulse or respiratory effort.
The physician documented, "...a gunshot wound to the mid thoracic back with no exit wound. has bilateral bs [breath sounds] with bagging [manual Ambu bag]". The patient had no pulse. DED physician #2 performed an emergent left thoracotomy at the 5th intercostal space and found a large quantity of clotted and unclotted blood. The DED physician documented the heart was flaccid and the physican could palpate a large hole in the posterior wall of the heart. Resuscitation efforts were stopped and Patient #5 expired on 11/24/16 at 1:16 PM. The cause of death was "GSW [gunshot wound]"..


17. An email from the TBI Assistant Special Agent in Charge sent to this office verified the following information via email on 12/13/16 at 2:43 PM: "... Both officers involved in the shooting are employees of the [local police department] and the names have not been released...On the date of the incident (11/24/16), one involved officer was assigned to [working in Hospital #1's] DED and the second officer responded from a patrol unit...The investigation is still active and ongoing with the TBI". No further information could be gathered at this time.