HospitalInspections.org

Based on observation, record review and interview, the facility failed to complete an entry on the central log for all patients who presented to the Psychiatric Crisis Department (PCS); and failed to have EMTALA law signage posted conspicuously in 4 of 5 patient areas (Involuntary Entrance, waiting area, intake area and deescalating rooms); failed to ensure that patients presenting to the PCS department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received a comprehensive Medical Screening Exams (MSE) for each visit per facility policy for eight of 20 patients (Patients #1, 2, 4, 5, 6, 7, 9 and 10) in a sample of 20 medical records reviewed; and failed to ensure that patients presenting to the PCS department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received appropriate stabilizing treatment prior to discharge for two of 20 patients (patients #9 and 10) in a sample of 20 medical records reviewed. The cumulative effect of these deficiencies potentially affect all patients seeking emergency treatment for psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression at the facility.

Findings include:

The facility staff failed to ensure that EMTALA law signage was conspicuously posted in 4 of 5 patient areas (Involuntary Entrance, waiting area, intake area and deescalating rooms). See tag A2402.

The facility staff failed to ensure that a current, completed log was maintained for the PCS department. See tag A2405.

The facility failed to ensure that patients presenting to the PCS department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received a comprehensive MSE per facility policy for eight of 20 patients (Patients #1, 2, 4, 5, 6, 7, 9 & 10) in a sample of 20 medical records reviewed. See tag A2406.

The facility failed to ensure that patients presenting to the PCS department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received an appropriate received stabilizing treatment prior to discharge for two of 20 patients (Patients # 9 and 10) in a sample of 20 medical records reviewed. See tag A2407.

Based on observation and interview the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) law signage was posted in 4 of 5 patient areas (Involuntary entrance, waiting areas, intake area and de-escalating rooms) in the Psychiatric Crisis Service (PCS) department.

Findings include:

On 7/31/18 at 9:50 AM one EMTALA law sign was observed at the entrance to the "Voluntary" entrance door of the ED. There was no signage observed in the "Involuntary" Entrance, waiting areas, intake or deescalating rooms.

An interview was conducted on 7/31/18 at 3:55 PM with Deputy Administrator A, during which he/she was asked "The only sign for EMTALA law observed was at the voluntary entrance were there any others?" Staff A stated "No, that is the only one we have posted.

Based on record review and interview the facility staff failed to ensure that there was a completed central log entry for each individual who presented to the Psychiatric Crisis Service (PCS) department for 7 of 7 months reviewed (1/1/18-7/31/18).

Findings include:

Review of the facility policy entitled "Psychiatric Crisis Service (PCS) Policy and Procedure" last reviewed on 3/29/2018 revealed on page four item "D. Ongoing Assessment/Planning/Intervention/Evaluation. 5. Nursing staff and Psychiatrist will complete the census log."

Review of the "MILWAUKEE COUNTY BEHAVIOR HEALTH PATIENT/CENSUS LOG" for the PCS department 1/1/18-7/31/18 on 7/31/18 at 1:00 PM revealed that there were numerous blank entries under " admit time, medical record number, patient name, date of birth, race, gender, legal status, registered nurse assigned, priority, physician assigned, medical clearance sent and returned time, disposition, time orders written on patient, PCS (Psychiatric Crisis Service) discharge time, registered nurse discharge note completed, and (if admitted) the time that report was called by the registered nurse to the receiving unit." There was no fully completed entry from "1/1/18-7/31/18."

An interview was conducted with Deputy Administrator C on 7/31/18 at 3:45 PM who was queried as to the expectations for completion of the central log and responded "It should absolutely be completed on each entry. I didn't know that wasn't being done and it isn't."

Based on record review and interview the facility failed to ensure that all patients that presented to the Psychiatric Care Services (PCS) department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received a comprehensive medical screening exam for each visit per facility policy in eight of 20 medical records reviewed (Patient's # 1, 2, 4, 5, 6, 7, 9 and 10).

An Immediate Jeopardy (IJ) was determined on 8/9/18 at 3:50 PM regarding the facility's failure to ensure that patients presenting to the Psychiatric Crisis Service (PCS) department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received a comprehensive Medical Screening Exams (MSE) per facility policy for eight of 20 patients (Patients # 1, 2, 4, 5, 6, 7, 9 and 10) in a sample of 20 medical records reviewed. The facility's failure has the potential to affect all patients who present to the PCS department seeking emergency services for psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression

The Director of Nursing was notified on 8/9/18 at 3:52 PM that an immediate jeopardy(IJ) had been identified.

The IJ was unremoved at the time of exit.

Findings include:

1. Review of the facility policy titled "Psychiatric Crisis Service (PCS) Policy and Procedure" last reviewed on 3/29/2018 revealed under "STANDARDS" bullet point #3 "Medical problems will be assessed and treated appropriately according to the PCS Priority Rating System and standards of care." The facility policy continued on page two item "B. Triage Procedure: 1. Determine whether an overtly threatening medical, mental, or behavioral crisis exists, which requires immediate intervention. a. These patients need immediate assessment by the RN, and immediate referral to a PCS psychiatrist for evaluation and/or treatment; patients with urgent or emergent medical needs will be sent to the appropriate Emergency Department via paramedics or ambulance when clinically indicated. b. When behavior is not controllable by any other means, restraint will be initiated in accordance with Medical Staff/Nursing Staff policy. c. Once the above have been resolved or ruled out, verify the patient's legal status (voluntary vs. involuntary). 2. If during the triage process the RN (Registered Nurse) decides there is clinical reasoning for a Brief Assessment (assessment completed in the security area) to occur, the RN will request consultation for a brief assessment from a PCS psychiatrist. The RN and PCS psychiatrist will consult and reach agreement as to whether a brief or full assessment is completed. If agreement is not reached, a full assessment will be completed. If a brief assessment is done, the following needs to be completed and documented: a. The RN will complete an Individual Progress Note that includes the patient's reason for presenting in PCS, reason for completion of brief assessment vs. full assessment, disposition, and documentation of vital signs. b. The psychiatrist will complete the physician Brief Assessment, Emergency Medical Screen, and SAFE-T (suicide and safety risk assessment completed by psychiatrist). c. The Brief Assessment will then be listed on the PCS log as B.A. for that patient. 3. While assessing the patient, the RN will assign and implement an initial priority level based on the urgency and severity of the patient's needs. 4. In compliance with provisions of COBRA[Consolidated Omnibus Budget Reconciliation Act]/EMTALA[Emergency Medical Treatment and Labor Act], all patients entering PCS are required to have an Emergency Medical Screen by a psychiatrist. D. Ongoing Assessment/Planning/Intervention/Evaluation 1. Upon completion of the RN intake assessment, the RN will give a psychiatrist a verbal report on the patient and the paperwork, including the triage priority level. The psychiatrist will then perform the full psychiatric assessment starting with the Emergency Medical Screen. 2. Patients with a priority level of 1 or 2 will, at a minimum receive a medical screening exam and stabilizing treatment before proceeding further in the PCS process. G. Admission to Observation Status If the PCS psychiatrist determines that there is the need for brief treatment and/or a more extended period of observation in order to evaluate the physical and mental status of an individual, the patient will be placed on Observation Status. Patients may be put on Observation Status as an alternative to inpatient hospitalization when they are experiencing a mental health crisis and need brief intensive assessment and treatment. Treatment is designed to be less than 48 hours in duration. Patients who are appropriate for admission to Observation may have: Persistent or emergent symptoms or behaviors potentially dangerous to self or others."

2 a. Patient #10's medical record was reviewed on 7/31/18 at 4:45 PM. Patient #10 had a medical history of "unspecified psychosis (likely drug-induced) and ASPD (Antisocial Personality Disorder) and had presented to the PCS unit on the following date, including 7/5/18.

b. On 7/5/18 at 5:58 AM an "Brief Assessment" was completed by Psychiatrist M documented on Patient #10 "The prior two times required sheriff assistance with pt's (patient's) refusal to leave, the second of which nearly resulted in pt being tased. [He/she] returns this time under ED (emergency detention) after breaking a window at a gas station. [He/she] banged [his/her] head in the squad care and said [he/she] wanted to kill [him/her]self. Not psychotic. Not manic. Completely able to control [his/her] own behavior. Not hallucinating. Thoughts organized enough to design methods in which to appear psychotic. Will discharge to police custody. Pt is primarily ASPD (Antisocial Personality Disorder) and is malingering psychosis. [He/she] is consistently disruptive to the safety of the PCS patients and staff." There was no completed Medical Screen Exam/EMTALA form documented for this visit per facility policy.

3a. Patient #9's medical record was reviewed on 7/31/18 at 4:25 PM. Patient #9 had a history of Cluster B Personality Disorders/traits, Psychotic disorders, conduct disorders and symptoms, antisocial behavior, aggression, impulsivity and presentd to the PCS department on the following dates, including 6/8/18 and 6/11/18.

b. On 6/8/18 at 5:30 AM "Mental Status Exam" completed by Psychiatrist J documented on Patient #9 "Appears stated age, casual clothes, short hair, walking around the unit attempting to escalate with staff members. Eye contact intense. Speech loud. Behavior: aggressive. Mood {profane word}, affect angry, threatening, labile. TP (thought process): Able to answer some questions from certain RN staff appropriately, but otherwise mostly responds with {profanity}. TC (thought content): perseverating {sic}on wanting to fight various staff members. Endorsed HI (homicidal ideations) without specific plan. Did not endorse suicidal thoughts." Patient was discharged to "self" and had to be escorted off facility grounds by sheriff as was refusing to leave. The documented Medical Screen Exam/EMTALA form was incomplete with no detail regarding how the patient arrived to the hospital, why [he/she] was angry and the police were called to remove [her/him]. In addition, there was no documented Brief Assessment or SAFE-T assessment completed for this visit per facility policy.

c. On 6/11/18 at 4:50 AM "Brief Assessment" completed by Psychiatrist Q documented on Patient #9 "called police and requested to be taken to PCS because "I need my medications. States [he/she] wants [his/her] thyroid medication and [his/her] Depakote, patient was seen in PCS yesterday and was discharged home. Patient does not have any other complaints at this time other than requesting [his/her] medications. Mental Status: Alert and oriented noted to be labile and dramatic presentation in triage area. Mood-ok, affect-labile, TP goal directed, denies having SI/HI (suicidal ideations/homicidal ideations) with no intent or plan, denies having A/V/H (auditory or visual hallucinations), no internal preoccupation noted. Plan: patient was encouraged to contact her medical doctor for her thyroid medication. [He/she] was also encouraged to contact [his/her] case manager to get [his/her] psych medications as well. Intervention Safety Plan: Treatment plan to address/reduce current risk: Created or reviewed safety plan in collaboration with patient, Reviewed or adjusted medications, Provided crisis line information." Patient was discharged to the police. There was not a documented Medical Screen Exam/EMTALA form completed for this visit per facility policy.

4a. Patient #1's medical record was reviewed on 7/31/18 at 1:15 PM. Patient #1 had a diagnosis of Schizoaffective disorder and was brought into PCS on 7/5/18 by law enforcement officers after being physically aggressive and threatening someone with a knife at place of residence. There was no documented SAFE-T for this visit. Patient #1 was discharged with law enforcement to jail from PCS unit, charges were eventually dropped.

b.On 7/5/18 at 2:53 PM "Brief Assessment" documented "Mental status: wnl (within normal limits) no RTIS, RRR, L/S (unsure of abbreviations), SI/HI, nor any thoughts of harm directed elsewhere. [He/she] does have some delusional content pertaining to possible possessions or relationships with peers that are not fully based in reality, but non to the point where violence/aggression are directed as such. Pt presents in law enforcement custody today after a battery complaint at the clients AFH [unsure of abbreviation] where he/she] had threatened staff. Pt will be released to the custody of law enforcement and is fit for confinement."

5a. Patient #7's medical record was reviewed on 7/31/18 at 4:00 PM. Patient #7 had a history of multiple visits to the PCS department for chronic depression requesting counseling for past trauma, but refusing to take psychotropic medications and not keeping follow up appointments for counseling. Patient #7 presented to the PCS department on the following dates, including 6/3/18, 6/10/18, 6/14/18, 6/17/18, 6/20/18, 6/29/18, 6/30/18, 7/7/18, 7/8/18, 7/10/18 and 7/12/18.

b. On 6/3/18 at 5:29 AM an "Individual Progress Note" completed by Psychiatrist V that documented on Patient #7 "Pt seen and discussed with RN. [He/she] presents here on daily basis and states [he/she] had argument with mom and sister and they called police. States they told [him/her] not welcome to come back to house. [He/she] states [he/she] did not want harm anyone. States [he/she] is homeless but does not want to go to shelter "as I do not like it", [he/she] states. [He/she] is asking for extra sandwiches to take along and states [he/she] will figure out where else to go. [He/she] reports [he/she] is not taking medications and believes [he/she] does not need them. Plan will d/x (discharge) to self." There was no documented Medical Screen Exam/EMTALA form or SAFE-T assessment for this visit per facility policy.

c. On 6/10/18 at 8:43 PM a "Brief Assessment" completed by Psychiatrist W that documented on Patient #7 "Pt here seeking "inpt (in patient) services", but I'm not willing to take meds [medications]. "I've been drugged before." Pt claims to have made a SA (suicide attempt) yesterday, points to inner thigh and states that [he/she] cut. However, did not seek help until today, when [he/she] went to ER (emergency room). States they discharged [him/her], did not need stitches. [He/she] said they discharged [him/her] for just the same complaints that [he/she] is making here. [He/she] says that [he/she] needs psychiatric help, but is not interested in meds. [He/she] indicates that [he/she] has insurance and [he/she] will call for an outpt (out patient) therapist. There is nothing acute in [his/her] presentation, no change since last week. It seems [he/she] was just looking for shelter. [He/she] kicked [his/her] mothers door in today but was not arrested. Pt is not psychotic, voices no plans for suicide or homicide, is shelter seeking. States [he/she] does not like the shelters, so is given bus tickets and will find [his/her] way to a friend's house. Will discharge with bus tickets." There was no documented Medical Screen Exam/EMTALA form or SAFE-T assessment for this visit per facility policy.

d. On 6/14/18 at 5:47 AM a "Brief Assessment" completed by Psychiatrist M that documented on Patient #7 "Police were called to sister's home after pt exhibited bizarre behavior. This is [his/her] fifth PCS visit in the last thirty days. Upon arrival [he/she] stated [he/she] wanted a sandwich, juice and a blanket. [He/she] is very well known to PCS. Plan No SI/HI; no indication for hospitalization. Will discharge to self." There is no documented Medical Screen Exam/EMTALA for this visit as per facility policy.

e. On 6/17/18 at 1:24 PM a "Brief Assessment" completed by Psychiatrist Q that documented Patient #7 "Presented to PCS vol (voluntarily), by police when [he/she] requested [him/her] to bring here. Patient states [he/she] is feeling depressed and wants to be admitted. States [he/she] however does not need any medications as [he/she] has been drugged before. Reports [he/she] does get angry easily and feels like hurting people when [he/she] is angry. Plan patient encouraged to go to shelter at this time [he/she] was encouraged to seek services on an outpatient basis. [He/she] can pursue counseling to begin with. List of places provided to the patient and [he/she] was given bus ticket to go to shelter." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

f. On 6/20/18 at 9:12 AM a "Brief Assessment" completed by Psychiatrist M documented that Patient #7 "Is here as a police-escorted voluntary. "I don't know why I'm here. I need help, whatever type of help y'all {sic} can give me." Pt is a high utilizer {sic} of PCS, usually for shelter reasons. Calm and cooperative. Appears intoxicated. Speech slurred. Denied SI (suicidal ideations). Vague HI (homicidal ideations) no intent or victim. Plan Will allow pt to sober up in PCS and discharge to self in the morning." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

g. On 6/29/18 at 1:41 AM a "Brief Assessment" completed by Psychiatrist X documented that Patient #7 "26 yo presenting in typical manner, vol (voluntarily) via police. Homeless but c/o (complaints of) past trauma that [he/she] wants counseling for and will not take meds. Not acutely suicidal. Not psychotic. Will discharge to outpt (out patient)." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

h. On 6/30/18 at 5:16 AM a "Brief Assessment" completed by Psychiatrist S documented that Patient #7 "Pt is irritable, alert and oriented. Angry when told that [he/she] does not have an acute psychiatric condition and call writer a {explanative}. [He/she] is goal directed and not internally preoccupied. Plan: Pt escalated when challenged about being admitted. [He/she] was removed via sheriff." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

i. On 7/7/18 at 3:50AM a Brief Assessment " completed by Psychiatrist S documented that Patient #7 [His/Her] last presentation was last week when [he/she] called writer a {expletive} and was summarily discharged from PCS. [He/she] presents now as a voluntary, clearly seeking shelter. Denies SI and HI, denies psychotic sx (symptoms). Thought process is linear, thought content shows no evidence of hallucinations, delusions. Plan: will allow to stay in PCS, discharge as soon as buses start running." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

j. On 7/8/18 at 4:04 AM a "Brief Assessment" completed by Psychiatrist G documented that Patient #7 "Said [he/she] needs medication for 'schizophrenia and depression.' [He/she] named Sertraline and Quetiapine as the specific medications [he/she] was looking for. Mental Status: very somnolent. Speech is soft. Eye contact is minimal. Mood is 'not good'. Affect is consistent with somnolence. Thought process is organized. No obvious evidence of psychosis. [He/she] made vague SI statements to the RN (registered nurse) but none to me. Plan: Will allow to sleep in PCS overnight. Discharge in AM." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

k. On 7/10/18 at 1:31 AM a "Brief Assessment" completed by Psychiatrist Z documented that Patient #7 "Presented to PCS voluntarily because of the ptsd (post traumatic stress disorder) and the anxiety and the wanting to kill people. [He/she] has missed his appointment at 16th St clinic because [he/she] forgot. [He/she] understands fully that should [he/she] harm someone [he/she] would be criminally charged and 'I would go to jail.' Acute danger to self or others: Yes." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

l. On 7/12/18 at 5:42 AM a "Brief Assessment" completed by Psychiatrist M documented that Patient #7 "This is the pt's ninth PCS presentation in the last thirty days.'I need help. I'm going through some stuff. I'm post traumatic, depression, schizophrenic, bipolar...' I explained that pt needs to follow up as an outpatient with these concerns, and [he/she] simply kept repeating 'post traumatic...depress...schizophrenic...bipolar.' Mental Status: Entirely goal-oriented. Not disorganized or distractible. Not internally preoccupied. No mention of SI/HI. Affect bright. Pt was discharged with bus tickets." There was no documented Medical Screen Exam/EMTALA form for this visit as per facility policy.

6a. Patient #2's medical record was reviewed on 7/31/18 at 1:30 PM. Patient #2 had a diagnosis of Schizophrenia and was brought to the PCS department on the following dates, including 4/15/18 by the police department and spent 24 hours in observation status.

b. On 4/15/18 at 1:32 PM a "Individual Progress Note" completed by Registered Nurse NN documented "45 year old [male/female] arrives to PCS on ED (emergency detention) with MPD (Milwaukee Police Department) after Patient #2's rooming house manager stated patient "pooped on the floor in the bedroom and was stepping into it on purpose. Patient slapped [manager name] glasses off her face and pt was outside with no socks or shoes on or jacket for 30 minutes. Patient is cooperative during triage and nursing assessment. Patient states [his/her] name is Bruno Mars and states [he/she] is [opposite sex]." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment completed for this visit as per facility policy.

7a. Patient #4's medical record was reviewed on 7/31/18 at 2:10 PM. Patient #4 had a diagnosis of Schizoaffective Disorder and Borderline Personality Disorder who was taken to the PCS department on the following dates, including 2/13/18 and 2/28/18.

b. On 2/13/18 at 12:47 PM there was a documented "Discharge Summary Report" that documented under "Special Instructions: Avoid alcohol and drugs, Return to PCS, call 911 or go to nearest ER for suicidal thoughts. Brief Clinical Summary: (blank) Brief Summary of Medical Treatment: (blank)." There was no note describing the chief complaint during that visit and that the patient was stabilized prior to discharge. There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment completed for this visit per facility policy.

c. On 2/28/18 at 7:53 PM an "Individual Progress Note" completed by Registered Nurse R documented "[Patient #4's name] presented to PCS on an ED issued by MPD regarding the named subject, who had been verbally abusive to staff and had forcibly pushed a resident. Upon encountering the patient, [he/she] was also aggressive with the CART (community behavioral response team) and [he/she] was patient {taken} into custody. (Psychiatrist Z) did assess the patient and has determined that the patient would be admitted in-patient on unit 43C (facility inpatient unit)." There was no note describing the chief complaint during this visit. There was a documented Medical Screen Exam/EMTALA form that was incomplete for this visit as per facility policy. There was no documented SAFE-T assessment or Brief Assessment for this visit per facility policy.

8a. Patient #5's medical record was reviewed on 7/31/18 at 2:33 PM. Patient #5 had a diagnosis of Psychotic and Mood disorders and presented to the PCS department on 6/12/17 after being aggressive to staff in group home.

b. On 6/12/18 at 3:00 AM a "Individual Progress Note" completed by Psychiatrist Q documented on Patient #5 "here on ED after [he/she] got upset with the staff at the group home and stated that [he/she] felt like harming self. Patient currently denies any thoughts of self harm in PCS. Patient claims [he/she] is not happy with [his/her] living situation. States [he/she] is a Jehovah's witness and feels like the staff does not respect it. Patient states [he/she] does not get along with the staff and does not want to be there. States [he/she] is taking [his/her] medications as prescribed. Patient apparently got upset and threw a plate at the staff. Currently denies having SI/HI, no intent or plan, denies having A/V/H , no delusions. Will d/c the patient to GH as [he/she] does not appear to be in crisis and consistently denies having SI/HI at this time." There was no documented Medical Screen Exam/EMTALA form or Brief Assessment for this visit per facility policy.

9a. Patient #6's medical record was reviewed on 7/31/18 at 3:40 PM. Patient #6 had a diagnosis of Schizoaffective disorder and presented to th PCS department on the following dates, including 6/14/18, 6/18/18, 6/21/18, 6/23/18, 6/30/18 (2 visits), 7/7/18, 7/8/18, 7/9/18, 7/11/18, 7/13/18, 7/14/18, 7/15/18, 7/17/18 (2 visits), 7/19/18, and 7/21/18.

b. On 6/14/18 at 7:40 AM a "Individual Progress Note" completed by Registered Nurse AA documented on Patient #6 "the patient presents to PCS escorted by the Milwaukee Police Department. In triage the patient stated that [he/she] was not really suicidal but [he/she] wants to talk to someone about [his/her] problems. [Psychiatrist M] spoke with the patient. The patient was discharged from 43-C (facility in patient unit) on 6/12/18. The patient was provided with two bus tickets and the phone number for the crisis line." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment for this visit per facility policy.

c. On 6/18/18 at 7:18 AM a "Individual Progress Note" completed by Psychiatrist V documented on Patient #6 "Pt seen by the door briefly. [He/she] reports she called police while sitting outside by her GH as [he/she] wanted to talk to someone. [He/she] is non-specific as to what [he/she] needed to talk about and presents here frequently. [He/she] denies suicidal ideations and homicidal ideations. RN will call group home for clarification before being discharged." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

d. On 6/21/18 at 12:47 PM an "Individual Progress Note" completed by Psychiatrist P documented on Patient #6 "24 y/o (year old) who claimed [he/she] was brought here by the police after [he/she] was 'walking around'. [He/she] denied A/V H , denied any SI/HI, [he/she] denied any AODA (drug use or dependence). Patient did not meet the criteria for admission, was encouraged to contact [his/her] clinic and try to set up an appointment to meet with someone." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

e. On 6/23/18 at 6:55 AM an "Individual Progress Note" completed by Registered Nurse H documented on Patient #6 "24 y/o presents to PCS with MPD. The officer says they were at St. Joseph hospital for another issue when they went outside patient approached them and [he/she] had suicidal thoughts. The doctor was notified and came to the door to see the patient and a brief assessment was done." On 6/23/18 at 6:31 AM an "Individual Progress Note" completed by Psychiatrist U documented "Note: See brief assessment." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

f. On 6/30/18 at 2:07 AM an "Individual Progress Note" completed by Registered Nurse BB documented on Patient #6 "came with Milwaukee Police dept. Patient came to facility wanting to talk to someone. Patient requesting facility change [his/her] medication. Patient vital signs stable. Patient denies thoughts of harming self or others. Patient denies medical problems. Patient no distress noted. [Psychiatrist L] came to door to assist with assessment. Patient given 2 bus tickets and nourishment." On 6/30/18 at 1:43 AM an "Individual Progress Note" completed by Psychiatrist L documented on Patient #6 "Note: Please refer to Brief Assessment form." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

g. On 6/30/18 at 5:04 PM an "Individual Progress Note" completed by Psychiatrist T documented on Patient #6 "See Brief Assessment." At 5:10 PM a "Individual Progress Note" completed by Registered Nurse H documented on Patient #6 "presents here with the police, the officers said [he/she] flagged them down and reported that [he/she] had suicidal thoughts. [He/she] requested to come here to speak with a doctor. Upon arrival patient says the doctor is [his/her] friend and [he/she] came to get some sandwiches and juices. Patient was discharged from PCS at 1700 (5:00 PM)." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

h. On 7/7/18 at 2:21 AM an "Individual Progress Note" completed by Psychiatrist S documented on Patient #6 "See brief assessment." At 3:45 AM "Individual Progress Note" completed by Registered Nurse CC documented "Pt was brought in by the police on a voluntary. It was reported that the pt was at Planet Fitness removing clothing. Then writer was told by police that [he/she] made SI (suicidal ideations) statements. Unable to assess pt because [he/she] refused to answer question. Plan is to continue to monitor through the night d/c in the AM." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

i. On 7/8/18 at 4:55 PM an "Individual Progress Note" completed by Psychiatrist DD documented on Patient #6 "Please see brief assessment for today's progress note." At 5:05 PM Registered Nurse EE documented "Pt is a 24 yo brought to PCS by squad and seeking voluntary admission. Pt has an alert in [his/her] chart stating that [he/she] needs attending triage at the door. MD [Medical Doctor] met pt at the door for brief assessment. Pt denied any symptoms of medical issues and refused VS (vital signs). Pt was offered medication, referrals to outpatient psychiatric services, and a list of homeless housing. Pt refused all stating that [he/she] just wanted sandwiches, juice and bus passes. MD cleared pt to be discharged." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

j. On 7/9/18 at 12:50 PM an "Individual Progress Note" completed by Psychiatrist M documented on Patient #6 "Note: See brief assessment." At 1:49 PM "Individual Progress Note" completed by Registered Nurse H documented "24 yo present here with MPD [he/she] went into the district police station and said [he/she] felt like talking to someone. Patient appeared tired and says [he/she] wants sandwiches & juice and wants to talk about [his/her] day. [Psychiatrist M] was notified and saw patient in intake and a brief assessment was completed." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

k. On 7/11/18 at 8:46 AM an "Individual Progress Note" completed by Psychiatrist P documented on Patient #6 "Patient is a 24 yo[year old] brought to PCS as a voluntary. [He/she] apparently flagged the police down and asked to be brought here. Patient appears to be at baseline, even less irritable than yesterday. [He/she] did not meet the criteria for inpatient Rx (treatment) at this time. [He/she] was given a shelter list and requested sandwiches before [he/she] left." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

l. On 7/13/18 at 5:38 AM an "Individual Progress Note" completed by Registered Nurse GG documented on Patient #6 "patient presents to PCS via MDP. Patient states "I need to be admitted. Patient also presented with no pants or shoes on. Patient was seen as a brief assessment, given shoes and pants as well. Was given 2 bus tickets and discharged." There was no documented Medical Screening Exam, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

m. On 7/14/18 at 2:35 AM an "Individual Progress Note" completed by Psychiatrist HH documented on Patient #6 "Note: see brief assessment." At 9:21 AM an "Individual Progress Note" completed by Psychiatrist K documented "Note: Please see brief assessment." At 9:36 AM an "Individual Progress Note" completed by Registered Nurse II documented "24 year old who is very well known to pcs (was discharged this am @ 0600). Pt was conveyed to PCS by Wauwatosa PD-[he/she] was reported (by a citizen) with self-injurious bx (behaviors) hitting self in the head. Pt denies si/hi/avh. Pt denies any pain or discomfort. Per MD pt will d/c to home via Wauwatosa PD @840." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

n. On 7/15/18 at 8:17 AM an "Individual Progress Note" completed by Psychiatrist JJ documented on Patient #6 "Note: See brief assessment." At 10:56 AM an "Individual Progress Note" completed by Registered Nurse II documented "pt presents to pcs on a voluntary basis. Pt is observed with baseline behaviors-inappropriate laughter/tangential speech/disheveled appearance. Pt states-"I want to be here" Pt met with MD-brief assessment. Per MD pt discharged to home bus passes given at 730." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

o. On 7/15/18 at 10:38 PM an "Individual Progress Note" completed by Registered Nurse KK documented on Patient #6 "Brought in voluntarily by MPD at 2154 (9:54 PM). States [he/she] was depressed after having a falling out with a friend. States [he/she] hears voices all the time. Brief assessment completed in triage by [Psychiatrist Q]. Will stay on an extended evaluation and be discharged in the AM." On 7/16/18 at 3:27 AM "ADDITIONAL NOTE" completed by Registered Nurse GG documented "Patient was yelling out in the day room. Doctor ordered Olanzapine 5 mg PO (by mouth). Attempt made to give patient medication and [he/she] threw the pill and cup across the floor." "Individual Progress Note" completed by Psychiatrist Q at 6:36 AM "patient slept overnight in PCS. [He/she] denies having SI/HI with no intent or plan, denies having A/V/H, no delusions. Will d/c patient to group home. Patient will be given bus tickets." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

p. On 7/17/18 at 6:09 AM an "Individual Progress Note" completed by Psychiatrist LL documented on Patient #6 "24 year old with schizoaffective who presents voluntary and now wants to leave. States that [he/she] just came in and now would like 2 bus tickets. States [he/she] is safe to leave and denies any SI or HI. Affect: agitated. TP: disorganized. TX: preseverates {sic} on coming to PCS." There was no documented Medical Screen Exam/EMTALA form, Brief Assessment or SAFE-T assessment documented for this visit per facility policy.

q. On 7/17/18 at 1:14 PM an "Individual Progress Note" completed by Psychiatrist W documented on Patient #6 "Note: See brief eval [evaluation]." At 1:32 PM an "Individual Progress Note" completed by Registered Nurse Y documented "Patient conveyed to PCS by West Allis Po

Based on record review and interview the facility failed to ensure patients who presented to the Psychiatric Crisis Service department with an emergency medical condition (EMC) received stabilizing treatment prior to discharge in three of 20 records reviewed (Patient's # 9, and 10) in sample of 20 medical records reviewed .

An immediate jeopardy (IJ) was identified on 8/9/18 at 3:50pm regarding the facility's failure to ensure that patients presenting to the PCS department with psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression received an appropriate received stabilizing treatment prior to discharge for two of 20 patients (Patients #9 and 10) in a sample of 20 medical records reviewed. The facility's failure has the potential to affect all patients who present to the PCS department seeking emergency services for psychiatric symptoms, including suicidal and/or homicidal ideations and/or aggression.

The Director of Nursing was notified on 8/9/18 at 3:52 PM that an IJ had been identified.

The IJ was unremoved at the time of exit.


Findings include:

Review of the facility policy titled "Psychiatric Crisis Service (PCS) Policy and Procedure" last reviewed on 3/29/2018 revealed on page two item "B. Triage Procedure:" under #2 "If during the triage process the RN (Registered Nurse) decides there is clinical reasoning for a Brief Assessment (assessment completed in the security area) to occur, the RN will request consultation for a brief assessment from a PCS psychiatrist. The RN and PCS psychiatrist will consult and reach agreement as to whether a brief or full assessment is completed. If agreement is not reached, a full assessment will be completed. If a brief assessment is done, the following needs to be completed and documented: a. The RN will complete an Individual Progress Note that includes the patient's reason for presenting in PCS, reason for completion of brief assessment vs. full assessment, disposition, and documentation of vital signs. b. The psychiatrist will complete the physician Brief Assessment, Emergency Medical Screen, and SAFE-T (suicide and safety risk assessment completed by psychiatrist). c. The brief Assessment will then be listed on the PCS log as B.A. for that patient. 3. While assessing the patient, the RN will assign and implement an initial priority level based on the urgency and severity of the patient's needs. 4. In compliance with provisions of COBRA[Consolidated Omnibus Budget Reconciliation Act]/EMTALA[Emergency Medical Treatment and Labor Act], all patients entering PCS are required to have an Emergency Medical Screen by a psychiatrist. D. Ongoing Assessment/Planning/Intervention/Evaluation 1. Upon completion of the RN intake assessment, the RN will give a psychiatrist a verbal report on the patient and the paperwork, including the triage priority level. The psychiatrist will then perform the full psychiatric assessment starting with the Emergency Medical Screen. 2. Patients with a priority level of 1 or 2 will, at a minimum receive a medical screening exam and stabilizing treatment before proceeding further in the PCS process. G. Admission to Observation Status If the PCS psychiatrist determines that there is the need for brief treatment and/or a more extended period of observation in order to evaluate the physical and mental status of an individual, the patient will be placed on Observation Status. Patients may be put on Observation Status as an alternative to inpatient hospitalization when they are experiencing a mental health crisis and need brief intensive assessment and treatment. Treatment is designed to be less than 48 hours in duration. Patients who are appropriate for admission to Observation may have: Persistent or emergent symptoms or behaviors potentially dangerous to self or others."

Patient #10's medical record was reviewed on 7/31/18 at 4:45 PM. Patient #10 had a medical history of "unspecified psychosis (likely drug-induced) and ASPD (Antisocial Personality Disorder". Patient #10 presented at the PCS department on the following dates, including 7/1/18, 7/2/18, and 7/4/18.

On 7/1/18 at 10:23 AM a "Individual Progress Note" completed by Psychiatrist L documented on Patient #10 "[Patient #10's name] was involuntarily brought here because a witness observed [him/her] mumbling incoherently to [him/her]self and lighting a t-shirt with a cigarette lighter and throwing it on top of a bush. Upon speaking with the patient, it becomes clear that [he/she] is delusional. [He/she] states (as has on previous PCS visits) that police in Brown Deer are trying to abduct children. [He/she] makes several other claims that seem implausible and at times incomprehensible. [He/she] states that [he/she] has 'no problems' and [he/she] just wanted to let us know about those abductions. At first, [he/she] requests some psych medications which [he/she] has been off of for a while, including Depakote. Upon Further discussion, [he/she] agrees to instead take nourishment, make a phone call, then asks for bus tickets so that [he/she] can go to church. Denies any SI (suicidal ideations)/HI (homicidal ideations)/AVH (auditory/visual/hallucinations) or other symptomatic concerns. Does not appear to be an imminent threat to [him/her] self or others. No aggressive or inappropriate behavior at PCS. Will discharge with bus tickets. Provided crisis line and discussed 12-step options, which patient politely declines." "Individual Progress Note" dictated on 7/1/18 at 12:33 PM by Registered Nurse O revealed "Pt's assessment complete. Pt states [he/she] needs medications. Pt comes to PCS often. Pt states [he/she] was trying to release the spirits that were in the bush. Pt begin talking about (unknown name) being [his/her] cousin and [he/she] comes to [him/her] in [his/her] dreams and tells [him/her] things. Pt provided nutrients. Case reviewed by psychiatrist. Pt sitting in waiting room. Pt shows no signs of distress or agitation. Pt will be discharged back to home when [he/she] feels safe." There was no documented treatment for presenting behavioral symptom.

On 7/2/18 at 8:41 AM an "Individual Progress Note" completed by Psychiatrist M documented Patient #10 arriving to PCS with law enforcement after "running in the middle of the streets avoiding officers. Had a lighter and cell phone in hand and stated to officers that we will have to kill [him/her] before will come with us. After in custody we spoke to witness who stated that [Patient #10's name] was aggressively panhandling and stopping traffic in street. [Patient #10] also lit a flag on the south end of building on fire and threatened to burn down building. In triage [he/she] refused to cooperate with staff, refused to take shoes off, refused vital signs and refusing to answer any questions. Was making verbal threats towards the doctor 'I'm going to kill my doctor.' Patient discharged to home with two bus tickets for transportation. All personal belongings was returned to [him/her] prior to leaving. Patient ambulated independently with a steady gait out of the crisis Center at 7:59 AM." "Brief Assessment" completed by Psychiatrist M at 7:55 AM documented "Pt is here under emergency detention after being discharged from PCS less than 24 hours ago. [He/she] is well known to me from numerous prior PCS encounters. Pt was hostile and uncooperative in triage, threatening to kill all of [his/her] doctors. Will discharge to self. Pt's presentation is consistent with [his/her] well documented prior diagnoses. [He/she] has already undergone one psychiatric emergency assessment today and was thought then, as now, to not benefit from hospitalization. [He/she] appears at baseline. [He/she] is capable of controlling [his/her] own behavior. Threats of violence are volitional and not secondary to mental illness, so not modifiable by hospitalization." There was no documented treatment for presenting behavioral symptom.

On 7/4/18 at 11:56 AM "Individual Progress Note" completed by Registered Nurse N documented that Patient #10 "[He/she] then stated 'Yes' to being suicidal but denies HI and AVH . [He/she] was seen as a Brief Assessment. [He/she] was sitting in triage refusing to leave stating 'I'm not going no where until I make sure my daddy ain't[sic} dead. (Psychiatrist O) is my real daddy. They kidnapped me.' Patient was provided with water and juices for hydration as well as nutrients. MD [Mecical Doctor] notified. Sheriff's department called since patient was refusing to leave. Two bus tickets provided for transportation. Discharge to home, ambulated independently with a steady gait out of the Crisis Center at 11:24 AM. Escorted off the property by two sheriff's officers." "Brief Assessment" at 11:23 AM by Psychiatrist M "I'm here to stay because David Clark is my father. Y'all{sic} don't believe me but that's the truth. (Psychiatrist P) he my father. He my blood father. My mother said I have to stay here to get medication until she come get me. I'm suicidal." " Pt is well known to me from numerous PCS encounters. [He/she] presents as voluntary. Despite endorsement of delusional thought content, [he/she] appears entirely focused with no observable sign of psychosis whatsoever {sic}. Mental Status: Manipulative. Goal-oriented and reality-based. Speech nonpressured. Euthymic. Not internally preoccupied. Affect bright. Plan: Pt appears at baseline. I see no acute factors that full PCS assessment would modify. Will discharge with bus tickets." "SAFE-T" assessment dictated at 11:25 AM by Psychiatrist M revealed "Ideation?: Yes Plan?: No Intent?: No Intervention Safety Plan Documentation: SAFE-T abbreviated due to brief assessment. Pt is endorsing vague, contingent SI without plan in place. Endorsement of SI appears linked to not wanting to be discharged. [He/she] shows no signs of being so psychiatrically decompensated to be imminently suicidal." There is no documented treatment for presenting behavioral symptom for this visit.

On 7/4/18 (visit #2 for this date) at 3:47 PM "Brief Assessment" completed by Psychiatrist M documented on Patient #10 "Pt returns to PCS less than five hours after last discharge (which required assistance of Sheriff) due to unruly behavior in the community. [He/she] appears unchanged from [his/her] previous presentation today. [He/she] was uncooperative in triage. Mental Status: Goal-oriented. No indication of psychosis. Not internally preoccupied or responding to internal stimuli. No grandiosity or delusions. Speech non pressured. Plan: Pt was discharged to self. [He/she] is malingering psychosis and is unwilling to maintain appropriate behavior. No modifiable factors for hospitalization." There is no documented treatment for presenting behavioral symptom for this visit.

Patient #9's medical record was reviewed on 7/31/18 at 4:25 PM. Patient #9 had a history of Cluster B Personality Disorders/traits, Psychotic disorders, conduct disorders and symptoms, antisocial behavior, aggression, impulsivity and presented to the PCS department on the following dates, including 6/10/18 and 6/11/18.

On 6/10/18 at 5:29 AM "Brief Assessment" completed by Psychiatrist K documented on Patient #9 " Patient with a history of schizoaffective disorder vs. personality disorder who present voluntarily by police escort with various complaints, reportedly seeing dead people in [his/her] house, needing [his/her] Depakote (if it is the pink kind), and needing to go to Dewey (a different local facility). [He/she] denies suicidal ideation and reports homicidal ideation toward the world with reported plan of 'lava.' [He/she] denies abnormal perceptions at time of interview, requests that the police clean [his/her] house of the dead people and 'dope and drugs' [he/she] denies recent use of alcohol and drugs. After being asked a series of questions, [he/she] asks if I would like to see [his/her] penis. Mental Status: [He/she] stares at me at times, being mute for intermittent periods. Affect is euthymic, mildly irritable. Thought processes are tangential. Thought content: denies suicidal ideation, reports homicidal ideation toward the entire world with plan of'lava'. No abnormal perceptions at time of interview but reportedly recent visual hallucinations with no evidence of internal preoccupation. Insight and judgment appear limited." On 6/10/18 at 5:29 AM "SAFE-T" assessment documented by Psychiatrist K under "Plan: given patient's lack of cooperation with intake process, [he/she] was discharged home." Under "Intervention Safety Plan" documented "Treatment plan to address/reduce current risk: Attempted to decrease access to firearms and other lethal means, Consulted with other professionals, Initiated, reviewed, and/or modified suicide observation status, Reviewed or adjusted medications, Moved to higher or lower level of care, Provided crisis line information. Although patient requested to go to (different facility), police were explicitly instructed not to convey [him/her] to (different facility) in line with EMTALA law." There was no documented treatment for the presenting behavioral symptom for this visit.

On 6/11/18 (2nd visit for that date) at 7:44 PM "Brief Assessment" completed by Psychiatrist J documented on Patient #9 " 'I want to be admitted to restart my medications' This patient is well known to me from a previous presentation on 6/8/18. At that time, [he/she] was not psychotic, but was extremely aggressive towards staff, in a manner consistent with [his/her] personality disorder. [He/she] has had two additional presentations, and [he/she] was sent home both times. The patient reportedly was at [his/her] case manager and was refusing medications because they "don't work." [He/she] stated that if [he/she] doesn't get help, [he/she] would 'blow up buildings' Discussed that these issues should be handled as an outpatient, and [he/she] became physically threatening, approaching me aggressively. [He/she] was redirected by staff. [He/she] was given sandwiches and juice as well as bus ticket, access clinic info, and shelter information. States wants to be admitted to restart [his/her] medications and for food, but is reportedly refusing medications from case manager. Is denying SI/HI, does not appear to be an imminent threat to [him/her] self or others. However, [he/she] remains at chronically high risk of harming others. There are no modifiable risk factors that would be improved by inpatient admission. Furthermore, admission is likely to reinforce maladaptive coping mechanisms." "Mental Status" completed at 7:49 PM by Psychiatrist J documented "Behavior: singing, lying on ground, climbing on chairs, redirectable. Speech: loud. Mood "fine", affect: superficially silly, then threatening when discharged discussed. TP (thought process): logical, goal directed. TC (thought content): denies SI/HI. Not reacting to internal stimuli. Insight: fair, acting in a goal-directed manner. Judgement: partial, utilizing poor coping mechanisms. Plan: Provided with nourishment, bus pass, crisis line, access clinic info, and shelter information. Discharged to shelter." There was no documented treatment for the presenting behavioral symptom for this visit.

On 7/31/18 at 1:25 PM an interview was conducted with Nurse Manager A who confirmed missing assessments for Patient's # 8, 9 & 10. Questioned Nurse Manager A what assessments are required by a psychiatrist on every patient? Nurse Manager A stated "I don't really know."

An interview was conducted with Psychiatrist D on 7/31/18 at 11:00 AM. When asked where documentation was expected in a patient medical record stated "There should always be a SAFE-T assessment, EMTALA form and other than that there are separate forms including individual progress notes, medication administration records that would document evaluations."