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Based on interview and record review, the hospital failed to follow their policies in the emergency department (ED) when:

1. There was no documented evidence patients or their representative were informed of the reasons and risks/benefits of the transfers for patients, who were placed on a 5150 hold (involuntary psychiatric hold for a mental health crisis for up to 72 hours) and transferred to another facility for four patients (Patients 4, 7, 12 and 24). Also, Transfer Summary was missing for four patients (Patients 8, 14, 16, and 28);

2. Elopement assessment and/or imminent Risk Assessment were not performed for 11 patients (Patients 1, 2, 4, 7, 8, 10, 11, 13, 22, 24, and 30);

3. MERT (Mobile Emergency Response Team) consult Notes were unavailable for two patients (Patients 2 and 7) in their medical record;

4. Patients's vital signs were not monitored every two hours for six patients (Patients 1, 11, 23, 26, 27 and 30);

5. A copy of 5150 hold order was unavailable in the medical record for eight patients (Patients 7, 8, 10, 16, 23, 28, 30 and 31);

6. ED staff did not follow the hospital's elopement policy when Patient 1 eloped; and,

7. Suicidal assessment or reassessment was not performed every two hours for two patients (Patients 2 and 10).

These deficient practices placed the health of patients at risk.

FINDINGS:

1. Review of Patient 4's ED notes, 9/27/22, indicated the patient was a 17-year-old female brought in by ambulance for suicidal ideations after taking multiple medications with the intent to kill herself. Patient 4 was on a 5150 hold. Patient 4 was medically cleared for transfer to a higher level of care due to psychiatric services not available at the hospital.

During a concurrent interview and record review on 11/7/22 at 12:10 p.m. with the Emergency Department Manager (EDM), Patient 4's Transfer Summary, dated 9/27/22 was reviewed. The Transfer summary indicated, "Patient acknowledgement for medical and non-medical transfers" section of the transfer summary was not completed, evidenced by a line through the section and "5150" written in place of the signature/date. The check box stating "Unable/unwilling to sign" was not checked. The EDM stated if the patient or parent refuses to sign the "Patient Acknowledgement for Medical and Non-Medical Transfers" then the box is checked unwilling to sign (on the transfer summary) indicating the patient/parent was provided the information about the transfer.

During an interview on 11/7/22 at 2:30 p.m. with Registered Nurse 9 (RN), RN 9 stated she was under the assumption patients did not have to sign (the acknowledgement section) of the transfer form and stated, "I usually just cross it off".

Review of Patient 7's ED Physician notes, dated 8/31/22, indicated the patient was suicidal and was placed on a 5150 hold.

During concurrent interview and record review with the Director of the Emergency Department (DED), on 11/7/22 at 2:05 p.m., she confirmed a line was marked through the patient acknowledgement section and "5150" was written. The DED confirmed the form should have been fully completed and should indicate if the patient was willing to sign or not sign the form.

Review of Patient 12's ED Physician Notes, dated 5/30/22, indicated the patient presented to the ED after she attempted to jump out of a car into roadway, a 5150 hold was placed, and after treatment in the hospital, she was transferred to another hospital for suicidal ideation.

Review of Patient 12's Transfer Summary, dated 5/30/22, indicated, a section "PATIENT ACKNOWLEDGEMENT FOR MEDICAL AND NON-MEDICAL TRANSFER" was crossed out with "5150" written. There was no documented evidence their family were informed and agreed with the patient's transfer.

During an interview on 11/4/22 at 8:47 a.m., the EDM reviewed Patients 7 and 12's clinical record and stated for patients under a 5150 hold, the section asking for patient's acknowledgement on Transfer Summary, was crossed out and staff wrote down "5150". She stated the section should be complete with the patient or family signatures, indicating they agreed or refused the transfer after they were fully informed about the transfer.

Record review of Patient 8's ED notes, dated 8/29/22, indicated Patient 8 had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was on a 5150 hold for "harm to others."

During interview with the EDM, on 11/4/22 at 10:40 a.m., she indicated she believed Patient 8 was transferred to another facility for care. She confirmed there was no transfer form in Patient 8's medical record. She indicated staff don't always fill out the transfer form which confirms the patient has been accepted by the facility to which they are transferring.

Review of Patient 14's ED Physician Notes, dated 5/26/22, indicated the patient was brought into the ED, accompanied by law enforcement, for suicidal ideation and placed on a 5150 hold.

Review of Patient 14's ED Discharge Note, dated 5/26/22, indicated the patient was transferred to a mental health facility. There was no transfer form completed, indicating the patient was informed of risks and benefits of the transfer, whether the patient was informed and agreed with the transfer. There was no information regarding receiving physician/hospital information, mode of transfer, and status of the patient at the time of transfer.

During an interview on 11/4/22 at 9 a.m., the ED manager (EDM) reviewed Patient 14's medical records and confirmed there was no Transfer Summary.

Review of Patient 16's ED physician Notes, dated 5/19/22, indicated the patient brought in by ambulance, with law enforcement, after she cut her left wrist for suicidal ideation. Patient 16 was placed under a 5150 hold, received laceration repair in the ED, and was transferred to CSP (Crisis Stabilization Program), accompanied by law enforcement. There was no Transfer Summary completed in the record.

During an interview on 11/4/22 at 9:44 a.m., EDM confirmed that Patient 16's Transfer Summary was missing.

Review of Patient 28's ED Physician Notes, dated 8/4/22, indicated the patient, a 16-year-old male, presented "for medical clearance prior to transfer to CSP after being placed on a 5150 hold for danger to self and others." It stated Patient 28 made numerous homicidal statements towards his father.

Review of Patient 28's medical records indicated there was no Transfer Summary.

During a record review and a concurrent interview on 11/7/22 at 2 p.m., the EDM stated when law enforcement takes the patient to CSP, the ED staff did not complete the transfer summary.

During a review of Patient 24's medical record, indicated the patient was seen in the hospital's emergency department by Emergency Department Physician M on October 29, 2022. Emergency Department Physician M placed Patient 24 on a 5150 hold and ordered a safety attendant. In his ED Physician Notes, dated October 29, 2022 at 5:00 p.m., Emergency Department Physician M noted Patient 24 was suicidal and "... medically cleared for evaluation at CSP ...". Emergency Department Physician M transferred Patient 24 to CSP, noting Patient 24's condition was stable. In his ED Physician Notes Addendum, dated October 30, 2022 at 8:29 a.m. Emergency Department Physician G indicated he assumed care for Patient 24 and "... [Patient 24] has been accepted for transfer to CSP for further care and evaluation ...". In her ED Discharge Note - Text, dated October 30, 2022 at 11:03 a.m., Registered Nurse 16 indicated Patient 24 was discharged. Patient 24's Transfer Summary form, signed by Emergency Department Physician G on 10/30/22 at 9:15 a.m., had sections filled out for clinical impression, reason for transfer, medical screening examination documentation, receiving physician, mode of transfer, patient status at time of transfer, name of employee at receiving hospital who accepted transfer, date and time of acceptance, and vital signs at time of transfer. In the section about patient acknowledgement for medical and non-medical transfers, the form noted "... I understand that ... I have a right to be informed of the reasons for my transfer. I acknowledge that I have received a medical screening examination and evaluation by a physician, or other appropriate personnel, and that I have been informed of the reasons for my transfer. All transfers have risks of traffic delays, accidents during transport, inclement [unpleasant] weather, rough terrain or turbulence, and the limitations of equipment and personnel present in the vehicle ...". There was no patient signature. There was "5150" written above the line for signature of patient/parent/legal representative.

During a concurrent interview and record review on 11/7/22 at 3:06 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 24's medical record was reviewed. When asked if there was any discussion with Patient 24 about the risks and benefits of transfer to Santa Cruz County Crisis Stabilization Program (CSP), the DED stated she did not see any specific note about the ED physician having a discussion with Patient 24 about the risks and benefits of transfer. The DED stated the ED physician should have a discussion about the risks and benefits of transfer with the patient. The DED stated, in the section about patient acknowledgement for medical and non-medical transfers, a patient signature should be obtained if the patient is appropriate or has capability to sign.

During an interview on 11/7/22 at 3:33 p.m. with Registered Nurse 9 (RN 9), RN 9 confirmed she was an Emergency Department (ED) nurse. RN 9 stated she was told 5150 patients are not supposed to sign the Transfer Summary form. RN 9 stated she was told the hospital does not need patient permission so the hospital does not need to have 5150 patients sign the Transfer Summary form.

Review of the hospital's policy, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", dated 8/17/22, indicated " ...the hospital sends to the receiving facility all medical records ...including ...(ii) the individual's informed written consent to transfer ..."

2. Review of Patient 1's ED notes, dated 9/24/22, indicated Patient 1 was placed on a 5150 hold in the ED because of grave disability (unable to provide a plan for providing self with shelter, food, or clothing).

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no elopement assessment was documented for Patient 1. The EDM confirmed an elopement assessment should be completed for each patient and should be part of the patient's medical record.

During interview with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no imminent risk assessment was documented for Patient 1.

Review of Patient 2's ED physician Notes, dated 9/29/22, indicated the patient was a 35-year-old who presented to the emergency department on a 5150 hold placed prior to arrival for being a danger to herself as determined by law enforcement. Patient 2 was admitted 9/29/22 at 7:00 p.m. and discharged 9/30/22 at 10:43 a.m. with law enforcement.

During concurrent interview and record review on 11/4/22 at 9:30 a.m. with the Director of Quality & Risk Management (DQRM), Patient 2's medical record was reviewed. DQRM confirmed there was no evidence of an elopement assessment completed.

During concurrent interview and record review on 11/7/22 at 12:10 p.m. with EDM, Patient 2's medical record was reviewed. The EDM confirmed there was no evidence of an imminent risk screening tool completed.

Review of Patient 4's ED notes, dated 9/27/22, indicated the patient was a 17-year-old female was brought in by ambulance for suicidal ideations, after taking multiple medications with the intent to kill herself. The patient was on a 5150 hold. Patient 4 was medically cleared for transfer to a higher level of care due to psychiatric services not available at the Hospital.

During concurrent interview and record review on 11/4/22 at 9:50 a.m., with the Director of Quality & Risk Management (DQRM), Patient 4's medical record was reviewed. DQRM confirmed there was no evidence of an elopement assessment completed.

During concurrent interview and record review on 11/7/22 at 12:15 with the EDM, Patient 4's medical record was reviewed. The EDM confirmed there was no evidence of an imminent risk screening tool completed.

Review of Patient 7's ED Physician notes, dated 8/31/22, indicated the patient was suicidal and was placed on a 5150 hold.

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no imminent risk assessment was documented for Patient 7.

Review of Patient 8's ED notes, dated 8/29/22, indicated Patient 8 had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was on a 5150 for "harm to others".

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no imminent risk assessment was documented for Patient 8.

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no elopement assessment was documented for Patient 8. The EDM confirmed an elopement assessment should be completed for each patient and should be part of the patient's medical record.

Review of Patient 10's ED triage note, dated 8/23/22, indicated Patient 10 was placed on a 5150 hold for suicidal ideation.

During interview and concurrent record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no imminent risk assessment was documented for Patient 10.

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no elopement assessment was documented for Patient 10. The EDM confirmed an elopement assessment should be completed for each patient and should be part of the patient's medical record.

Review of Patient 11's ED triage note, dated 8/27/22, indicated Patient 11 was placed on a 5150 hold for concern of danger to others.

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no imminent risk assessment was documented for Patient 11.

During an interview with the EDM, on 11/3/22 at 9:54 a.m., she confirmed the policy stated the imminent risk form is to be completed as an assessment, the imminent risk form was not consistently utilized in the ED, and staff was confused over who was to complete the assessment. The EDM stated the assessment is used to determine if a patient attendant is needed. The EDM further stated the imminent risk tool was not a part of the patient's electronic medical record.

During concurrent interview and record review with the EDM, on 11/7/22 at 11:27 a.m., she confirmed no elopement assessment was documented for Patient 11. The EDM confirmed an elopement assessment should be completed for each patient and should be a part of the patient's medical record.

Review of Patient 13's ED Physician Notes, dated 5/30/22, indicated the patient, a 16-year-old male, presented to the ED with suicidal ideation. The patient was placed on a 5150 hold prior to arrival at the hospital, evaluated and monitored in the ED, and discharged on 5/31/22. There was no documented evidence Imminent Risk Assessment Tool was utilized to determine the patient required a safety attendant during his ED stay.

During an interview on 11/7/22 at 11 a.m., the EDM reviewed Patient 13's medical record and confirmed Imminent Risk Assessment Tool was not utilized.

Review of Patient 22's ED Physician Notes, dated 6/10/22 indicated he presented to the ED after attempting to shoot himself with a gun. Patient 22 was placed on a 5150 hold. There was no documented evidence the Imminent Risk Assessment Tool was utilized to determine the patient required a safety attendant.

During an interview on 11/7/22 at 10:47 a.m., the Director of ED & Critical Care (DED) reviewed Patient 22's medical record and confirmed the Imminent Risk Assessment Tool was not utilized. The DED also confirmed no elopement assessment was documented for Patient 22. The DED confirmed an elopement assessment should be completed for each patient and should be part of the patient's medical record.

During a concurrent interview and record review on 11/4/22 at 2:57 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 24's medical record and the hospital's policy and procedure titled Elopement and Wandering Assessment and Prevention, approved 2/17/22, were reviewed. When asked if there was an elopement risk assessment performed for Patient 24, the DED stated the hospital uses the Columbia Suicide Severity Rating Scale. The DED confirmed the Columbia Suicide Severity Rating Scale is not an elopement-specific tool, and stated there was nothing in the electronic medical record (EMR) that was an elopement-specific tool. The DED stated the Imminent Risk Screening Tool is used to look at elopement risk and the need for a sitter. The DED stated the hospital hoped the Imminent Risk Screening Tool would be incorporated into the EMR, but the hospital was struggling with corporate to do that. When asked what was the hospital's practice for elopement risk assessment, the DED stated it was a conversation between the Emergency Department (ED) physician, ED primary nurse, and ED charge nurse to determine if a patient needs a sitter. The DED stated, in the policy, evaluating the need for a sitter means filling out the Imminent Risk Screening Tool.

During a concurrent interview and record review on 11/4/22 at 2:57 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 30's medical record and the hospital's policy and procedure titled Elopement and Wandering Assessment and Prevention, approved 2/17/22, was reviewed. When asked if there was an elopement risk assessment for Patient 30, the DED stated the ED physician had a discussion with nurses and determined Patient 30 needed restraints. When asked if an Imminent Risk Screening Tool should have been completed for Patient 30, the DED stated in theory, yes. The DED stated the Imminent Risk Screening Tool is not scanned into the electronic medical record.

During an interview on 11/7/22 at 2:09 p.m. with the DED, the DED stated there was nothing in the electronic medical record or on the Imminent Risk Screening Tool about elopement assessment risk score. The DED stated it was just based on the ED physician speaking with the ED nurse, and that discussion is not documented. When asked if the discussion should be documented, the DED stated probably. When asked how often elopement risk should be assessed, the DED stated every four hours.

During an interview on 11/3/22 at 9:58 a.m. with the Emergency Department Manager (EDM), the EDM stated emergency department staff should complete the Imminent Risk Screening Tool at the time of triage [process to categorize patients based on severity of illness in order to determine who needs to be seen first] or shortly after triage to see which patients need sitters. The EDM stated the hospital is inconsistently using the Imminent Risk Screening Tool. The EDM stated the Imminent Risk Screening Tool has not been utilized because ED staff thought the house supervisors were completing it, while the house supervisors thought ED nurses were completing it. The EDM stated ED staff was completing the Columbia Suicide Severity Rating Scale instead. The EDM stated she agreed the Columbia Suicide Severity Rating Scale was different from the Imminent Risk Screening Tool, and that the Columbia Suicide Severity Rating Scale only assessed for suicidal ideation [thinking about or planning to kill oneself] and not for homicidal ideation [thinking about or planning to kill others]. When asked what the hospital was using to determine if a sitter was needed, the EDM stated it was nursing judgment of the patient's thought process and flight risk.

Review of the hospital's policy and procedure titled Elopement and Wandering Assessment and Prevention, approved 2/17/22, indicated the policy applied to "... all inpatients and outpatients who are at high risk for wandering and elopement ... patients are considered high risk for elopement or wandering if they ... are legally committed ... are considered dangerous to self or others ... have a history of wandering or being missing ... lack cognitive ability or capacity to make relevant decisions ... have physical or mental impairments that increase their risk of harm to self or others. (May be on 5150 Holds) ...". The policy defined elopement as "... a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected. A patient may be aware that he/she is not permitted to leave, but does so with intent ...". The policy noted "... Patients shall be assessed at the time of admission and throughout their hospitalization for factors which place them at risk for elopement ..." and "... For patients identified as high risk for elopement or wandering, the nurse shall initiate the following interventions ... Evaluate placement of a sitter to monitor patient ...".

Review of the facility's policy, "Safety Attendant: For patients at risk for harm to self or others", dated 7/18/18. The policy indicated, " ...any patient believed to be at risk of injury to self or others will be assessed utilizing the Imminent Risk Screening tool to determine the type of safety attendant and level of observation needed."


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3. Review of Patient 2's ED physician Notes, dated 9/29/22 indicated the patient was a 35-year-old who presented to the emergency department on a 5150 hold placed prior to arrival for being a danger to herself as determined by law enforcement. Patient 2 was admitted 9/29/22 at 7:00 p.m. and discharged 9/30/22 at 10:43 a.m. with law enforcement. Patient 2 was medically cleared for transfer to a higher level of care due to psychiatric services not available at the hospital.

During a concurrent interview and record review on 11/4/22 at 9:30 a.m. with the Emergency Department Manager (EDM), Patient 2's medical record was reviewed. The ED Physician notes, dated 9/29/22 at 1:54 p.m. indicated "MERT [Mobile Emergency Response Team] declined to lift the hold ..." and an addendum to the ED Physician note added 9/30/22 at 10:28 indicated " ...seen again by MERT this morning and they declined to clear patient". The EDM confirmed there was no evidence of MERT documentation in Patient 2's medical record.

Record review of Patient 7's ED Physician notes, dated 8/31/22, indicated the Patient 7 was suicidal and was placed on a 5150 hold.

During concurrent interview and record review with the EDM, on 11/4/22 at 10:40 a.m., she indicated in a physician note that Patient 7's 5150 was lifted at 10:16 a.m. on 8/24/22. The EDM confirmed no note from the MERT provider lifting the 5150 hold in Patient 7's medical record. She indicated a note should be documented and in the Patient 7's clinical record.

Review of the hospital's policy, "Defining the Designated Record set", dated 11/1/2020, indicated third party health care provider records that have either been scanned into electronic medical record applications maintained by the provider or that have been incorporated into the individual's medical record in whatever format and available for future reference by the provider, or have been used in whole or in part to make Treatment decisions about the individual.

4. Review of Patient 1's ED physician notes, dated 9/24/22 at 2:42 p.m., indicated Patient 1 was brought to the ED by paramedics and placed on a 5150 hold for grave disability (inability to care for oneself because of inability to meet basic needs of food, clothing, or shelter).

Review of Patient 1's ED notes, dated 9/24/22, indicated the last documented vital signs for Patient 1 were completed 9/24/22 at 4:00 p.m. Review of Patient 1's discharge note indicated Patient 1 eloped at 8:32 p.m.

During concurrent interview and record review with the DED, on 11/7/22 at 2:05 p.m., the DED confirmed two sets of vital sign assessments were not documented for Patient 1. The DED confirmed vital signs should be take every two hours and should be documented in the patient's medical record.

Review of Patient 11's ED triage note, dated 8/27/22, indicated Patient 11 was placed on a 5150 hold for a concern of danger to others.

Review of Patient 11's ED notes, dated 8/27/22, indicated Patient 11 had vital signs documented at 8/28/22 at 00:24 a.m. and 8/28/22 at 6:40 am.

During concurrent interview and record review with DED, on 11/7/22 at 2:05 p.m., the DED confirmed two sets of vital sign assessments were not documented for Patient 11. The DED confirmed vital signs should be take every two hours and should be documented in the patient's medical record.

Review of Patient 23's ED Physician Notes, dated 6/25/22 indicated he presented to the ED for acute psychosis. Patient 23 was placed on a 5150 hold.

During concurrent interview and record review on 11/7/22 at 10:56 a.m. with the Director of ED & Critical Care (DED), Patient 23's vital signs flowsheet was reviewed. Patient 23's vital signs were taken on 6/25/22 at 6:27 a.m., 6/25/22 at 8:39 a.m., 6/25/22 at 11:09 a.m., and 6/25/22 at 2:06 p.m. The DED confirmed Patient 23 did not have vital signs taken every two hours.

Review of Patient 26's ED Physician Notes, dated 10/15/22 indicated she presented to the ED for suicidal ideation. Patient 26 was placed on a 5150 hold.

During concurrent interview and record review on 11/7/22 at 12 p.m. with the DED, Patient 26's vital signs flowsheet was reviewed. Patient 26's vital signs were taken on 10/15/22 at 2:33 p.m., 10/15/22 at 5 p.m., 10/15/22 at 9:30 p.m., 10/16/22 at 12:15 a.m., 10/16/22 at 3:41 a.m., and 10/16/22 at 6:13 a.m. Patient 26's vital signs were taken on 10/16/22 at 6 p.m., 10/17/22 at 1 a.m., 10/17/22 at 5:50 a.m., 10/17/22 at 9:05 a.m., 10/17/22 at 10 a.m., 10/17/22 at 1:24 p.m., 10/17/22 at 3:56 p.m., 10/17/22 at 6:41 p.m., 10/18/22 at 5:21 a.m., and 10/18/22 at 8:22 a.m. The DED confirmed Patient 26 did not have vital signs taken every two hours.

Review of Patient 27's ED Physician Notes, dated 8/21/22 indicated he presented to the ED for suicidal ideation. Patient 27 was placed on a 5150 hold.

During concurrent interview and record review on 11/7/22 at 11:15 a.m. with the DED, Patient 27's vital signs flowsheet was reviewed. Patient 27's vital signs were taken on 8/21/22 at 10:11 a.m., 8/21/22 at 1:02 p.m., 8/21/22 at 2:47 p.m., 8/21/22 at 5:11 p.m., 8/21/22 at 9 p.m., 8/22/22 at 12:58 a.m., 8/22/22 at 6:12 a.m., and 8/22/22 at 11:24 a.m. The DED confirmed Patient 27 did not have vital signs taken every two hours.

During a review of Patient 30's medical record, indicated Patient 30 was seen in the hospital's emergency department on October 4, 2022. Patient 30 arrived on 10/04/2022 at 5:27 p.m. In his note dated October 5, 2022 at 10:52 a.m., Registered Nurse 15 noted "... Patient discharged home as discussed ... ".

During a concurrent interview and record review on 11/4/22 at 2:57 p.m. with the DED, Patient 30's medical record was reviewed. Patient 30 had vital signs taken on 10/4/22 at 5:37 p.m., on 10/5/22 at 12:35 a.m., on 10/5/22 at 3:07 a.m., on 10/5/22 at 9:00 a.m., and 10/5/22 at 10:52 a.m. The DED confirmed Patient 30 did not have vital signs taken every 2 hours. The DED stated Patient 30 should have had vital signs taken every 2 hours.

Review of the hospital's policy, "Standard of Patient Care Emergency Department," dated 6/19/19 indicated all patients will be reassessed and have a complete set of vitals signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation) repeated and documented in the electronic health record every two hours.

5. Review of Patient 7's ED Physician notes, dated 8/31/22, indicated the patient was suicidal and was placed on a 5150 hold.

During concurrent interview and record review with the EDM, on 11/4/22 at 10:40 a.m., she indicated there was no 5150 hold orders in Patient 7's medical record.

Review of Patient 8's ED notes, dated 8/29/22, indicated Patient 8 had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was on a 5150 hold for "harm to others."

During interview with the EDM, on 11/4/22 at 10:40 a.m., she stated there were no 5150 hold orders in Patient 8's medical record.

Record review of Patient 10's ED triage note, dated 8/23/22, indicated Patient 10 was placed on a 5150 hold for suicidal ideation.

During interview with the EDM, on 11/4/22 at 10:40 a.m., she indicated there were no 5150 hold orders in Patient 10's medical record.

Review of Patient 16's ED physician Notes, dated 5/19/22, indicated the patient was brought in by ambulance, with law enforcement, after she cut her left wrist for suicidal ideation. The patient was placed under a 5150 hold, received laceration repair in the ED, and was transferred to CSP, accompanied by law enforcement. There was no 5150 hold orders placed in the medical record.

During an interview on 11/4/22 at 9:44 a.m., EDM confirmed a copy of Patient 16's 5150 hold order was missing in the patient's medical record.

Review of Patient 23's ED Physician Notes, dated 6/25/22 indicated he presented to the ED for acute psychosis. Patient 23 was placed on a 5150 hold due to the patient's erratic and threatening behavior.

During concurrent interview and record review on 11/7/22 at 10:56 a.m., the DED confirmed a copy of Patient 23's 5150 hold order was missing in the patient's medical record.

Review of Patient 28's ED Physician Notes, dated 8/4/22, indicated the patient, a 16-year-old male, presented "for medical clearance prior to transfer to CSP after being placed on a 5150 hold for danger to self and others."

During a record review and concurrent interview on 11/7/22 at 2 p.m., the EDM reviewed Patient 28's record and confined that the patient's 5150 hold order was not in the record.

Review of Patient 30's medical record, indicated Patient 30 was seen in the hospital's emergency department by Emergency Department Physician N on October 4, 2022. In his ED Physician Notes, dated October 04, 2022 at 9:29 p.m., Emergency Department Physician N noted he placed Patient 30 on a "... 5150 hold over concern about danger to self ...". There was no 5150 application form.

During a concurrent interview and record review on 11/7/22 at 3:06 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 30's medical record was reviewed. The DED was unable to find a copy of Patient 30's 5150 application form.

Review of Patient 31's ED Physician Notes, dated 9/23/22, indicated the patient was brought to the ED for worsening bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and placed on a 5150 hold after having endorsed suicide ideation.

During a record review and concurrent interview at 11/9/22 at 1:25 p.m., the EDM reviewed Patient 31's medical record and stated the patient's 5150 hold order was not in her medical record.

Review of the hospital policy, "72 Hours Holds 5150", dated 8/17/22, indicated Welfare and Institutions Code 5150 (W&I 5150) provides for the involuntary detention for evaluation and treatment of a patient, who, as the result of a mental disorder, is either a danger to other or to self, or who is gravely disabled as to be unable to provide for his or her basic personal needs for food, clothing, and shelter. It indicated the original document remains in the patient's medical record while they are registered at the hospital. If the patient is transferred to another facility during the 72-hour detention, a copy of the 5150 will be made for the hospital medical record and the original will be sent along with the patient to the accepting facility.

6. Record review of Patient 1's ED notes, dated 9/24/22, indicated Patient 1 was placed on a 5150 hold in the ED because of grave disability (unable to provide a plan for providing self with shelter, food, or clothing).

During interview with Registered Nurse 4 (RN 4), on 11/3/22 at 3:00 p.m., he indicated around the start of his shift on 9/24/22 at around 7:00 p.m. a fire alarm went off. He stated the staff in the ED checked on all the patients in the ED at this time and this was when the staff discovered Patient 1 was not in her room or in the ED.

During record review of Patient 1's ED Physician Notes, dated 8/24/2

Based on observation, interview, and record review, the hospital failed to post signs regarding patient rights under EMTALA (Emergency Medical Treatment and Labor Act) in the emergency department (ED) treatment rooms and in each waiting area. The deficient practices had the potential to cause patients to be unaware of their rights under EMTALA.

Findings:

During a tour of the ED on 11/1/22 at 9:35 a.m., with the Chief Nursing Officer (CNO), the Director of ED and Critical Care (DED), and the ED Manager (EDM), the lobby/waiting room and treatment areas were observed. The lobby included a registration desk and security desk on the right and a triage nurse desk on the left. The lobby also had four separate waiting areas and each waiting area had a set of chairs. There was one EMTALA sign in the waiting area across from the registration desk and another EMTALA sign in the waiting area across from the security desk. There were no EMTALA signs in the waiting areas across from the triage nurse desk where some patients were waiting.

During an observation on 11/1/22 at 10:10 a.m., there was no EMTALA sign in Room 20.

During a concurrent interview, the EDM confirmed there was no EMTALA sign in Room 20 and stated the ETMALA signs were in the lobby. She stated there were no EMTALA signs in any of the 24 ED treatment rooms.

Review of the hospital's policy, "Regulatory Signage Required Policy and Procedure," dated 2/1/22 indicated EMTALA signage "must be posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area)."

Based on interview and record review, the hospital failed to accurately maintain a central log of patients in the Emergency Department (ED), when Patient 17 was returned to the hospital's emergency department following a failed transfer to another facility and the facility did not reregister Patient 17 in the central log. This failure had the potential to risk the health and safety of Patient 17 by failing to identify all patients who enter the ED for treatment needed to stabilize the medical condition.

Findings:

Review of Patient 17's Emergency Department (ED) triage assessment notes, dated 10/21/22 indicated the patient presented to the ED for not answering questions appropriately and identifying as a lemur. Patient 17 was placed on a 5150 hold (involuntary psychiatric hold for a mental health crisis for up to 72 hours) and was admitted to the hospital.

Record review of Paatient 17's "Transfer Summary," dated 10/21/22 at 1:43 a.m., indicated Patient 17 was transferred to another facility for a "service not available : 5150 evaluation."

Record review of Patient 17's ED physician notes, dated 10/21/22 at 6:45 a.m., indicated Patient 17 was "refused" at the facility and brought back the ED by ambulance.

During interview with the Emergency Department Manager (EDM), on 11/5/22 at 10:05 a.m., she confirmed Patient 17 was brought back to the ED. She confirmed Patient 17 was not re-entered in the facility's central log. The EDM stated when Patient 17 was returned Patient 17 should have been re-entered in the log.

Review of facility policy, "Emergency Medical Care/Emergency Medical Treatment," dated 9/25/18, indicated the hospital will maintain one central log with the name of the patient, the date and time of arrival, the disposition, the means of arrival, the age/sex, record number, nature of complaint.

Based on interview and record review, the hospital failed to provide emergency services within their capability when:

1. A medical screening evaluation (MSE) was not performed after Patient 17 was returned to the hospital's emergency department following a failed transfer to another facility. This failure had the potential to risk the health and safety of the patient by failing to identify any treatment needed to stabilize the medical condition;

2. Law enforcement was utilized as a safety attendant for three patients (Patients 8, 18, and 21); and,

3. A safety attendant was not provided to monitor patients who had suicidal ideation and/or a safety attendant's document was incomplete indicating the patients were constantly monitored for 15 patients (Patients 2, 4, 7, 8, 11, 13, 18,19,20,21, 22, 23, 24, 31 and 32).

This failure had the potential to risk the health and safety of the patients.

Findings:

1. Review of Patient 17's Emergency Department (ED) triage assessment notes, dated 10/21/22 indicated the patient presented to the ED for not answering questions appropriately and identifying as a lemur. Patient 17 was placed on a 5150 hold (involuntary psychiatric hold for a mental health crisis for up to 72 hours) and was admitted to the hospital.

Review of Patient 17's Transfer Summary, dated 10/21/22 at 1:43 a.m., indicated the patient was transferred to another facility for a "service not available : 5150 evaluation."

Review of the ED physician notes, dated 10/21/22 at 6:45 a.m., indicated Patient 17 was "refused" at the receiving facility and returned to the ED by ambulance.

During an interview with the Emergency Department Manager (EDM), on 11/5/22 at 10:05 a.m., she confirmed Patient 17 was brought back to the ED. She confirmed no documentation Patient 17 was provided a new medical screening evaluation. She stated another MSE should have been completed after being returned to the ED.

Review of the hospital's policy "Emergency Medical Care/Emergency Medical Treatment," dated 9/25/18, indicated that all individuals who come to the hospital for treatment shall receive an appropriate medical screening examination and the hospital shall not delay in providing a medical screening examination. The policy further indicated this will be part of the patient's electronic medical record.

2. Review of Patient 8's ED notes, dated 8/29/22, indicated the patient had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was on a 5150 hold for "harm to others."

During an interview and concurrent record review with the DED, on 11/7/22 at 2:05 p.m., there was documentation on 8/29/22 at 5:29 a.m., Patient 8 had law enforcement at bedside and no note indicating a safety attendant was at bedside. The DED stated patients brought in on 5150 holds by law enforcement are considered "custody" patients and law enforcement will be with the patient. The DED confirmed the local law enforcement are not facility staff nor do they have any hospital training to be safety attendants.

Review of Patient 18's ED notes, dated 7/17/22, indicated the patient was placed on a 5150 hold by the law enforcement due to a suicide attempt. Patient 18's Columbia Suicide Severity Rate Scale (tool to assess the severity of the suicide ideation) indicated the patient was at a high risk for suicide. The suicide prevention interventions for Patient 18 included direct observation and providing a safety attendant.

Review of Patient 18's medical record indicated, on 7/17/22 at 8:05 p.m., the patient presented to the ED for evaluation of a suicide attempt, was placed on a 5150 hold, and on 7/17/22 at 9:44 p.m., the patient was transferred to another psychiatric facility, accompanied by law enforcement. During the Patient 18's ED stay, there was no documented evidence a safety attendant was provided.

During an interview with the EDM on 11/7/22 at 11:30 a.m., she stated Patient 18 was on a 5150 hold and there was no safety attendant needed for the patient because law enforcement was at the bedside with the patient during the ED stay.

Review of Patient 21's ED notes, dated 7/5/22, indicated the patient was placed on a 5150 hold by the law enforcement, due to suicidal ideation and danger to self and others. It indicated the patient presented to the ED on 7/5/22 at 7:24 p.m. and was transferred to a psychiatric facility, accompanied by the law enforcement on 7/5/22 at 9:30 p.m. During the patient's ED stay, there was no documented evidence a safety attendant was provided.

During an interview with EDM on 11/7/22 at 11:56 a.m., she stated Patient 21 was on a 5150 hold with the law enforcement and there was no need to provide a safety attendant because law enforcement was at the bedside with the patient.

Review of the hospital's policy, "Safety Attendant: For Patients at Risk for Harm to Self or Others" dated 7/18/18, indicated, "Patients assessed as a risk of harm to self or others ...will be placed on continuous direct line of sight observation", "Safety Attendant:...iii. Utilizes the Safety Attendant observer form for patients at risk for suicide...", and "Safety Attendant must be trained hospital personnel assigned to this role. A patient's family member, significant other, care partner or friend is not to be utilized."


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3. Review of Patient 2's ED record, dated 9/29/22, indicated the patient was a 35-year-old who presented to the emergency department on a 5150 hold placed prior to arrival for being a danger to herself as determined by law enforcement. Patient 2 visited the ED on 9/29/22 at 7:00 p.m. and was discharged on 9/30/22 at 10:43 a.m. with law enforcement. Patient 2 was transferred to a higher level of care due to psychiatric services not available at the hospital.

During a record review and concurrent interview, on 11/7/22 at 12:10 p.m., with the Emergency Department Manager (EDM), Patient 2's flow sheet, dated from 9/29/22 to 9/30/22, indicated a safety attendant as a suicidal intervention. There is no evidence of documentation by a safety attendant. The EDM confirmed there was no safety attendant documentation.

Review of Patient 4's ED record, dated 9/27/22, indicated the patient was a 17-year-old female brought in by ambulance for suicidal ideation after taking multiple medications with the intent to kill herself. Patient 4 was on a 5150 hold and was medically cleared for transfer to a higher level of care due to psychiatric services not available at the hospital.

During a record review and concurrent interview, on 11/5/22 at 9:30 a.m., with the Director of Quality & Risk Management (DQRM), Patient 4's physician orders, dated 9/27/22 at 12:18 p.m., indicated One on One observation (sitter) and the DQRM confirmed there was no documented evidence a safety attendant was provided.

Review of Patient 7's ED Physician notes, dated 8/31/22, indicated the patient was suicidal and placed on a 5150 hold.

During concurrent interview and record review, 11/7/22 at 2:05 p.m., with Director of the Emergency Department (DED), she stated the tool the facility used to identify if a patient had suicidal ideation and was at risk for self harm, was the C-SSRS (Columbia Suicide Severity Rating Scale; six screening questions used to identify individuals at risk for suicide). The DED confirmed Patient 7's C-SSRS, completed on 8/31/22 at 9:50 p.m., indicated a score of 11. The DED stated with this score the patient should have had a safety attendant due to suicide risk, but there was no documented evidence a safety attendant was provided for this patient.

Review of Patient 8's ED notes, dated 8/29/22, indicated Patient 8 had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was on a 5150 hold for "harm to others."

During concurrent interview and record review with the DED, on 11/4/22 at 10:40 a.m., she confirmed no documentation for a safety attendant was provided for Patient 8 and stated Patient 8 should have had a safety attendant present.

Review of Patient 11's ED triage note, dated 8/27/22, indicated the patient was placed on a 5150 hold for a concern of danger to others.

During concurrent interview and record review with the DED, on 11/4/22 at 10:40 a.m., she confirmed there was no documented evidence Patient 11 had a safety attendant and Patient 11 should have had a safety attendant present.

Review of Patient 13's ED Physician Notes, dated 5/30/22, indicated the patient, a 16-year-old male, presented to the ED with suicidal ideation. The patient was placed on a 5150 hold prior to arrival at the hospital, evaluated and monitored in the ED, and discharged on 5/31/22. There was no documented evidence a safety attendant was provided to Patient 13, to monitor him during his ED stay. There was no Safety Attendant Observation Form completed for Patient 13.

During an interview on 11/7/22 at 11 a.m., the EDM reviewed Patient 13's medical record and confirmed the patient required a safety attendant, but there was no evidence a safety attendant was provided.

A review of Patient 18's medical record indicated Patient 18 was placed on 5150 by the law enforcement due to the suicide attempt. Patient 18's Columbia Suicide Severity Rate Scale (tool to assess the severity of the suicide ideation) indicated Patient 18 was at high risk for suicide. The suicide prevention intervention for Patient 18 included direct observation and providing safety attendant.

A review of Patient 18's medical record indicated the patient was admitted to the ED for psych hold and evaluation due to the suicide attempt on 7/17/22 at 8:05 p.m. Patient 18 was discharged with the law enforcement to a psychiatric facility on 7/17/22 at 9:44 p.m. During the patient's ED stay, the law enforcement was utilized a safety attendant. There was no document indicated the hospital utilized a safety attendant for Patient 18's ED stay.

During an interview with ED Manager (EDM) on 11/7/22 at 11:30 a.m., she stated Patient 18 had 5150 hold order with the law enforcement, there was no safety attendant needed because the law enforcement was at the bedside with the patient during the ED stay.

A review of Patient 19's medical record indicated Patient 19 was on 5150 hold for suicidal ideation. Patient was admitted to the ED on 7/15/22 at 10:50 a.m. and discharged to a psychiatric facility on 7/15/22 at 8:50 p.m. There was one time entered on 7/15/22 at 11 a.m. on Patient 19's Suicide Risk Safety Attendant Observation Form.

During an interview with EDM on 11/7/22 at 11:40 a.m., she stated she "only" saw safety attendant documented the observation for Patient 19 on 7/15/22 at 11 a.m. and the rest safety attendant's documentation was "missing".

A review of Patient 20's medical record indicated Patient was on 5150 hold for the suicidal ideation. Patient 20's Suicide Severity Rate Scale indicated Patient 20 was at high risk for suicide. Patient 20 was admitted to the ED on 7/16/22 at 8:22 p.m. and discharged to a psychiatric facility on 7/17/22 at 3:27 a.m.

During an interview with EDM on 11/7/22 at 11:40 a.m., she stated there was no safety attendant document indicated the facility provided a safety attendant for Patient 20 during the ED stay.

A review of Patient 21's medical record indicated Patient 21 was on 5150 hold with the law enforcement due to suicidal ideation, and danger to self and others. Patient 21 was admitted to the ED on 7/5/22 at 7:24 p.m. and discharged to a psychiatric facility with the law enforcement on 7/5/22 at 9:30 p.m. During the patient's ED stay, the law enforcement was utilized a safety attendant. There was no document indicated the hospital utilized a safety attendant for Patient 21's ED stay.

During an interview with EDM on 11/7/22 at 11:56 a.m., she stated Patient 21 had 5150 hold order with the law enforcement, there was no safety attendant needed because the law enforcement was at the bedside with the patient during the ED stay.

Review of Patient 22's ED Physician Notes, dated 6/10/22, indicated the patient presented to the ED after attempting to shoot himself with a gun. Patient 22 was placed on a 5150 hold. There was no documented evidence a safety attendant was provided to the patient to monitor him during his ED stay.

During an interview on 11/7/22 at 10:47 a.m., the DED reviewed Patient 22's medical record and confirmed there was no Safety Attendant Observation Form completed for Patient 22.

During an interview on 11/9/22 at 2:45 p.m., the EDM reviewed Patient 22's medical record and confirmed the patient required a safety attendant.

Review of Patient 23's ED Physician Notes, dated 6/25/22 indicated the patient presented to the ED for acute psychosis. Patient 23 was placed on a 5150 hold.

Review of Patient 23's medical record indicated there was a safety attendant at Patient 23's bedside. There was no Safety Attendant Observation Form completed for Patient 23.

During an interview on 11/7/22 at 10:56 a.m., the DED reviewed Patient 23's medical record and confirmed there was no Safety Attendant Observation Form completed for Patient 23.

During a review of Patient 24's medical record, indicated Patient 24 was seen in the hospital's emergency department by Emergency Department Physician M on October 29, 2022. Emergency Department Physician M placed Patient 24 on a 5150 hold and ordered a safety attendant.

In his ED Physician Notes, dated October 29, 2022 at 5:00 p.m., Emergency Department Physician M noted Patient 24 was suicidal. In his Safe Room Checklist - Test note, dated October 29, 2022 at 7:41 p.m., Registered Nurse 4 indicated a safety attendant was present. In her Safe Room Checklist - Test note, dated October 30, 2022 at 7:25 a.m., Registered Nurse 16 indicated a safety attendant was present.

During a concurrent interview and record review on 11/7/22 at 3:06 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 24's medical record was reviewed. The DED confirmed Patient 24 had a safety attendant. The DED was unable to find safety attendant documentation in the medical record.

Review of Patient 31's ED Physician Notes, dated 9/23/22, indicated the patient was brought to the ED for worsening bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and placed on a 5150 hold after having suicide ideation.

During a record review and concurrent interview, on 11/9/22 at 1:25 p.m., the EDM reviewed Patient 31's clinical record and stated the patient required one on one safety attendant and the safety attendant's Safety Attendant Observation Form was incomplete. She stated there was no documented evidence a safety attendant was provided for Patient 31.

Review of Patient 32's ED Physician Notes, dated 9/22/22, indicated the patient presented with suicidal ideation.

Review of Patient 32's ED Discharge Note, dated 9/23/22 at 11:23 a.m., indicated the patient was transferred to another facility.

During a record review and concurrent interview, on 11/9/22 at 1:25 p.m., the EDM reviewed Patient 32's clinical record and stated the patient required a safety attendant. She confirmed there was no documented evidence a safety attendant was assigned to Patient 32 on 9/23/22.

Review of the hospital's policy, "Safety Attendant: For patients at Risk for Harm to Self or Others" dated 7/18/18, indicated, "Patients assessed as a risk of harm to self or others ...will be placed on continuous direct line of sight observation." "Safety Attendant:...iii. Utilizes the Safety Attendant observer form for patients at risk for suicide..."



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Based on interview and record review, the hospital failed to appropriately transfer four of 36 sampled patients (Patients 8, 16, 28, and 29) when there were no transfer forms and no documentation of an accepting facility and physician. These deficient practices placed the health of patients at risk.

Findings:

During a review of the hospital's policy and procedure titled Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy, reviewed 06/13/2022, defined transfer as the "... movement (including the discharge) of an individual outside the hospital's facilities at the direction of any person employed by or affiliated directly or indirectly with the hospital ...". The policy defined Emergency Medical Condition as "... 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 individual in serious jeopardy ...". The policy noted "... If the individual has an Emergency Medical Condition, the individual is to be treated in the DED [dedicated emergency department] until the condition is stabilized or the individual can be appropriately transferred ...". The policy defined Stabilized as when "... the treating physician has determined ... that the Emergency Medical Condition has been resolved ...". The policy indicated the individual may be transferred if " ... The receiving facility has available space and qualified personnel for treatment of the individual; and the receiving facility and receiving physician have agreed to accept the individual and to provide appropriate medical treatment ... The transfer is effecting [sic] using proper personnel and equipment, as well as necessary and medically appropriate life-support measures as clinically indicated ...".

During a review of the Santa Cruz County Crisis Stabilization Program (CSP) and Santa Cruz County Psychiatric Health Facility (PHF) brochures, undated, indicated CSP is a facility open 24 hours a day, seven days per week. The brochures noted CSP provides crisis evaluation, stabilization, and referral services for adults, children, and youth needing emergency mental health services. The brochures indicated patients receive comprehensive clinical assessment, medication management, development of a recovery plan, and referrals to services including community treatment resources and medical services. The brochures indicated if a patient's mental health emergency warrants admission to an inpatient facility, the patient will be referred to the adjacent Psychiatric Health Facility (PHF). The brochures noted the PHF is a locked acute psychiatric inpatient program for adults that is open 24 hours a day, seven days per week.

Review of Patient 8's ED notes, dated 8/29/22, indicated the patient had a history of schizophrenia (severe persistent mental illness that impairs thinking, feeling and behavior) and was placed on a 5150 hold for "harm to others."

During an interview with the Emergency Department Manager (EDM), on 11/4/22 at 10:40 a.m., she indicated Patient 8 was transferred, by law enforcement, to another facility for care.

Review of Patient 16's ED Physician Notes, dated 5/19/22, indicated the patient was brought to the ED by ambulance, with law enforcement, after she cut her left wrist for suicidal ideation. The patient was placed on a 5150 hold, received laceration repair in the ED, and was transferred to another facility by law enforcement.

Review of Patient 16's ED Discharge Note, dated 5/20/22, indicated the patient was transferred to another facility, accompanied by law enforcement. There was no documented evidence Patient 16's transfer was accepted from the receiving facility.

Review of Patient 28's ED Physician Notes, dated 8/4/22, indicated the patient, a 16-year-old male, presented to the ED "for medical clearance prior to transfer to CSP after being placed on a 5150 hold for danger to self and others." It indicated "The patient was medically cleared for transfer to CSP" and under "Disposition", it stated "Discharge ...Now, Home or self care" and asked the patient to follow up with a primary care provider as needed.

Review of Patient 28's ED Discharge Note, dated 8/4/22, indicated the discharge disposition was "Law Enforcement/Jail".

During an interview on 11/7/22 at 2 p.m., the EDM stated when law enforcement transfers the patient to CSP, the ED staff did not complete the transfer summary and did not require to have the receiving facility's acceptance.

Review of Patient 29's clinical record indicated Patient 29 was seen in the hospital's emergency department by Emergency Department Physician G on 10/10/22 at 3:17 p.m. Patient 29 was a 70-year-old female brought in by ambulance and law enforcement on a 5150 hold [involuntary psychiatric hold for patient deemed to be a danger to self, to others, or gravely disabled] for making suicidal statements and trying to run into traffic on the freeway. Emergency Department Physician G noted Patient 29 was "... brought on a 5150 hold for danger to self ...". Emergency Department Physician G noted her condition was stable and she was medically cleared to be discharged to the Santa Cruz County Crisis Stabilization Program (CSP). In his note dated October 10, 2022 at 6:05 p.m., Registered Nurse 17 indicated " ... plan for discharge, medically cleared, and sheriff to then take pt [patient] to CSP ...". In her note dated October 10, 2022 at 6:30 p.m., Registered Nurse 18 noted "... Pt care transferred to sheriffs, pt discharged. pt calm and cooperatively made it to sheriff vechicle [sic] ...". There was no documentation of CSP accepting Patient 29 or a physician accepting transfer of Patient 29 to CSP. There was no Transfer Summary form.

During a concurrent interview and record review on 11/4/22 at 2:57 p.m. with the Director of the Emergency Department and Critical Care (DED), Patient 29's medical record was reviewed, When asked if a psychiatrist [doctor specializing in mental health] saw Patient 29 in the Emergency Department, the DED stated she did not see any psychiatry notes. The DED was unable to find a Transfer Summary form in the medical record. The DED stated there probably was no transfer form since Patient 29 was taken by law enforcement to CSP. The DED stated, when law enforcement initiates a 5150 hold, law enforcement staff stays with the patient in the hospital's emergency department (ED) and then takes the patient to CSP. The DED stated law enforcement staff is maintaining legal custody of the patient. The DED stated the hospital is technically discharging the patient to law enforcement, who then transports the patient to CSP to be newly admitted. The DED stated the emergency department does not complete a Transfer Summary form because law enforcement is responsible for getting the patient to CSP, and that the ED is not calling for an ambulance to transport the patient to CSP.

During an interview on 11/7/22 at 2:09 p.m. with the Director of the Emergency Department and Critical Care (DED), the DED stated a 5150 patient brought into the emergency department by law enforcement is officially discharged into law enforcement custody for transport to CSP. The DED stated the 5150 hold is not lifted, it is still in effect. The DED stated law enforcement remain at the patient's bedside the entire time the patient is in the ED. The DED stated the emergency department physician intends for the 5150 patient to be discharged to law enforcement and then to get evaluated and treated at CSP. The DED stated the emergency department physician is aware he or she is discharging the 5150 patient to law enforcement, and assumes law enforcement will transport the 5150 patient to CSP. The DED stated there is no hospital policy regarding this process. The DED stated there is no ED physician to CSP physician discussion.

During a concurrent interview and record review on 11/9/22 at 2:20 p.m. with the DED, Patient 29's medical record was reviewed. When asked if there was any documentation in the medical record of Patient 29 being accepted by CSP or a CSP physician, the DED stated it would not be documented in the patient's chart because the patient is still on a legal hold by law enforcement.

During an interview on 11/8/22 at 10:45 a.m. with Emergency Department Physician E (EDP E), EDP E stated it was not uncommon for law enforcement to remain with a 5150 patient in the ED if law enforcement placed the 5150 hold. EDP E stated, for 5150 patients in the ED, the goal is to provide a medical screening examination and to arrange for a mental health evaluation. EDP E stated, by law, the patient requires a mental health evaluation by a mental health professional to determine if the 5150 hold is maintained or lifted. EDP E stated he does not lift 5150 holds. EDP E stated the 5150 patient's emergency medical condition (EMC) is not resolved until the patient has a mental health evaluation with a mental health professional. EDP E stated, after medically clearing the patient to indicate there is no contraindication for the patient to be seen by a mental health professional, the ED starts the process of transferring the patient to a psychiatric facility or obtaining a mental health evaluation in the ED. When asked when the ED physician's responsibility for the 5150 patient ends, EDP E stated when it ends when the patient leaves the ED through admission, discharge, or transfer. EDP E stated that he believes he has sent 5150 patients from the ED to CSP via law enforcement. When asked who decides the type of transportation for 5150 patients, EDP E stated he did not know who makes the final decision or what the hospital's policy is and that it was not something he was "super cognizant" of all the time. EDP E stated he believes the ED charge nurse and ED unit coordinator make arrangements for transporting patients to CSP after medical clearance. When asked if he has a discussion with the CSP physician when transferring patients to CSP, EDP E stated he does not do that. When asked if 5150 patients being transported to CSP by law enforcement staff was a patient transfer or a patient discharge, EDP E stated he did not know if it was splitting hairs but it was like the patient was medically cleared.

During an interview on 11/8/22 at 1:31 p.m. with Emergency Department Physician G (EDP G), EDP G stated for 5150 patients transported to CSP by law enforcement, it was a patient transfer. EDP G stated they cannot discharge 5150 patients unless the 5150 hold is evaluated and lifted. EDP G stated, for patients coming into the ED on a 5150 hold written by law enforcement, law enforcement staff remain with the patient until the patient is medically cleared to go to CSP and then transport the patient to CSP. EDP G stated these patients are in law enforcement "custody", meaning law enforcement wrote the 5150 hold and brought the patient to the ED, but he did not think these patients were formally charged with anything. When asked how this process started, EDP G stated he believes it is law enforcement policy and it started maybe around two to three years ago. When asked if CSP formally accepts the patient, EDP G stated he thinks the charge nurse would know the answer. EDP G stated it is usually much faster for law enforcement to transport patients to CSP. EDP G said, if law enforcement does not transport a 5150 patient to CSP, then he thinks CSP arranges for ambulance transportation. When asked if he has a say in how a 5150 patient is transported to CSP if law enforcement brings the patient to the ED, EDP G stated the patient does not need a monitor but needs secure transport so he or she cannot jump out.

During an interview on 11/8/22 at 3:09 p.m. with Emergency Department Physician I (EDP I), EDP I stated 5150 patients coming into the ED with law enforcement will be transported by law enforcement to CSP, and that this was a patient discharge. EDP I stated no one lifts the 5150 hold, that these patients go to CSP under the secure, protected transport of law enforcement. EDP I stated she was told the ED does not need to necessarily do the same things for 5150 patients in police "custody", such as the ED contacting CSP, CSP reviewing patient paperwork and letting the ED know if they can accept the patient, and CSP arranging for patient transportation. EDP I stated she does not think the ED needs to wait for CSP to accept the patient. EDP I stated she is not personally calling CSP when she sends a patient over. EDP I stated she does not decide the type of transportation when a patient is sent from the ED to CSP, she thinks CSP decides that.

During an interview on 11/8/22 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated the ED unit coordinator is an ED technician.

During an interview on 11/8/22 at 2:33 p.m. with the Emergency Department Technician H (EDT H), EDT H stated he initiates patient transfers as a unit coordinator. EDT H stated, for 5150 patients transported to CSP by ambulance, he faxes over patient information to CSP once the ED physician notifies him the patient is medically cleared. EDT H stated he then calls CSP to make sure they received the fax, CSP reviews the patient paperwork and calls the hospital ED with any questions or to accept the 5150 patient. EDT H stated the CSP charge nurse is the person who usually calls the ED. EDT H stated CSP arranges for ambulance transport and pick up time from the ED to CSP, not the ED unit coordinator. For 5150 patients transported to CSP by law enforcement, EDT H stated the unit coordinator just prints out patient paperwork and hands it to the ED nurse. EDT H stated the ED nurse gives the patient paperwork to law enforcement staff to take over to CSP. EDT H stated he is not sure how CSP is evaluating the patient's chart, and that the unit coordinator does not call CSP in this situation. EDT H stated, if a patient is transported by law enforcement, the ED nurse gives a courtesy call to CSP to let them know the 5150 patient is being transported by law enforcement. EDT H stated, for 5150 patients transported via law enforcement, no Transfer Summary form is filled out. EDT H stated he thinks it is law enforcement policy to remain with the 5150 patient in the ED until the patient is medically cleared, then the ED discharges the patient into law enforcement custody and law enforcement staff take the patient to CSP. EDT H stated he thinks this process started several years ago.

During an interview on 11/10/22 at 11:06 a.m. with Registered Nurse 11 (RN 11), RN 11 stated she is an ED nurse. RN 11 stated she was told if law enforcement brings in a patient on a 5150 hold, the law enforcement staff is required to stay with the patient in the ED and then the law enforcement staff would take the patient to CSP. RN 11 stated she believes this process started around February 2022. When asked if a safety attendant is required for the 5150 patient when law enforcement is present, RN 11 stated it is much nicer when law enforcement is present because the law enforcement staff watches the patient. When asked what kind of communication CSP receives before a patient is transported from the ED to CSP by law enforcement, RN 11 stated the ED nurse makes a courtesy call to CSP to let CSP know law enforcement is bringing a 5150 patient to CSP. When asked if this courtesy call takes place before or after the patient leaves the ED, RN 11 stated it occurs when the ED nurse has a moment to call, sometimes before the patient leaves the ED and sometimes after. RN 11 stated if the ED nurse cannot call CSP until after the patient leaves, CSP can read the patient's discharge papers and original 5150 form for themselves because those are given to the law enforcement staff who transport the patient to CSP.

During an interview on 11/10/22 at 2:12 p.m. with Registered Nurse 10 (RN 10), RN 10 stated she is an ED nurse. RN 10 stated she has worked as an ED charge nurse for two years. RN 10 stated, if CSP is on diversion [routing ambulances away from the facility when the facility cannot accept incoming ambulance patients] and law enforcement brings a 5150 patient into the ED, the 5150 patient will be transported from the ED to CSP by law enforcement and the patient will be a "walk in" to CSP. RN 10 stated this is a much faster process. RN 10 stated law enforcement staff take the original 5150 form and the patient's discharge paperwork over to CSP. RN 10 stated the 5150 patients taken by law enforcement to CSP are discharged from the ED, not transferred. RN 10 stated the hospital is not calling CSP for acceptance of patients. When asked how the ED knows CSP will accept the patient, RN 10 stated CSP will take "walk ins" even if they are on diversion to the hospital. When asked what she thinks about law enforcement remaining with patients in the ED when law enforcement writes the 5150 hold, RN 10 stated she thinks it is a great idea.

During an interview on 11/16/22 at 10:03 a.m. with the Director of the Emergency Department and Critical Care (DED), Emergency Department Manager (EDM), and Emergency Department Physician N (EDP N), the DED stated law enforcement told the hospital about one to two years ago that law enforcement staff are supposed to stay with the 5150 patient in the ED and then transport the patient to CSP. The DED stated the hospital was told the responsibility is with the law enforcement officer to get the 5150 patient to CSP, even if the patient stops at the hospital's ED for evaluation. The DED stated the hospital was not part of the decision-making process and that it did not have anything in writing from law enforcement. When asked if the hospital ever had discussions with law enforcement about this process, EDP N stated, in his opinion, it was helpful because the hospital gets someone else to watch the patient. When asked if sending a 5150 patient to CSP was a patient transfer or a patient discharge, EDP N stated it was not totally clear. EDP N then stated, until the 5150 patient gets to a facility where he or she can get psychiatric evaluation, the patient's emergency medical condition (EMC) is not resolved. EDP N stated, if he did not think it was safe to send a patient to CSP in the law enforcement vehicle, he would not do so. When asked what the difference was between a Basic Life Support (BLS) ambulance and law enforcement, EDP N stated not much since BLS ambulance staff have basic CPR [cardiopulmonary resuscitation, an emergency lifesaving procedure performed when heart stops beating] skills and law enforcement has basic CPR skills.

During a review of a letter from the County of Santa Cruz Sheriff-Coroner to the hospital, dated November 16, 2022, indicated "... local law enforcement will attempt to bring [patients] to the CSP only to be told the person will not be accepted until they are medically cleared by [hospital] staff ..." and that often CSP is declared "... to be in "Code Red," which means they will not accept any new admissions into the facility. Our law enforcement officers then bring the [patient] to your hospital, where they wait until ..." CSP is able to accept them. The letter indicated the Sheriff-Coroner had been strongly urged to keep a deputy with the patient in the ED while the patient waits for admission to CSP. The Sheriff-Coroner noted the four police departments in the county all agreed with this protocol and have their officers remain with the patient until CSP is able to accept the patient.

During an interview on 11/17/22 at 2:32 p.m. with the Director of Quality and Risk Management (DQRM) and the Patient Safety and Risk Manager (PSRM), the PSRM and DQRM stated they were not aware that 5150 patients transported from the ED to CSP by law enforcement did not have a Transfer Summary form, documentation of an accepting facility, or documentation of an accepting physician.

During a review of the hospital's policy and procedure titled Standard of Patient Care Emergency Department, approved 6/19/19, indicated "... Discharge from ED [emergency department] Care ... Verify transfers to another facility meet EMTALA guidelines ...".

During a review of the hospital's Medical Staff General Rules and Regulations, approved November 15, 2017, indicated "... EMERGENCY MEDICAL SERVICE ... Appropriate assessment, stabilization, and initial treatment shall be rendered to any sick or injured person who presents him/herself at the [Hospital] Emergency Department ... No patient will be transferred until the receiving practitioner and/or institution has been contacted and has consented to accept the on going care of that patient ...".

During a review of the hospital's Medical Staff Bylaws, approved June 16, 2021, indicated in Section 2.5 "... the ongoing responsibilities of each member of the medical staff include ... abiding by the medical staff bylaws, medical staff rules and regulations, and policies ...".

During an interview on 11/14/22 at 1:20 p.m. with the Medical Staff Director (MSDIR), the MSDIR stated physicians receive EMTALA training via a slide when they initially start at the hospital. The MSDIR stated physicians receive EMTALA module training annually via email. The MSDIR stated there is no test after the EMTALA training. When asked if there is tracking of the physician EMTALA training, the MSDIR stated she prints and saves her email after she emails the EMTALA module training out. When asked how the hospital knows the physicians reviewed the training and understand EMTALA, the MSDIR stated she did not have an answer.

During a concurrent interview and record review on 11/15/22 at 10:01 a.m. with the MSDIR, the hospital's Annual Medical Staff Education Module 2022, undated, was reviewed. The MSDIR stated there was only one slide for EMTALA training. The MSDIR stated the same slide was used for initial training of physicians when they start and for annual training. The page on Emergency Medical Treatment and Active Labor Act (EMTALA) noted descriptions on patient access to emergency services regardless of ability to pay, gender, race, and ethnicity; stabilizing treatment; medical screening exam; and emergency medical condition. The MSDIR confirmed there was no description about the requirements for appropriate transfer or central log. The MSDIR stated, at initial onboarding, physicians sign attesting they read all of the information. The MSDIR stated there is no attestation required for annual training.






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