HospitalInspections.org

Based on documentation review and staff interviews, the acute care hospital Emergency Department (ED) staff failed to follow the hospital's policies when the ED staff failed to provide an adequate medical screening examination to 2 of 26 sampled patients (Patients #4 and Patient #8) that presented to the ED and requested care. The administrative staff identified average of 2,686 patients per month who requested emergency medical care at the facility's dedicated emergency department.

Failure to follow the acute care hospital's policies that required the ED staff to provide an adequate medical screening examination within the facilities capabilities resulted in:
a. The hospital's ED staff discharged 1 pediatric patient with suicidal ideations to a group home without psychiatric evaluation.
b. The hospital's ED staff discharged 1 adult patient with psychiatric needs prior to psychiatric consultation. The patient returned the following day and required hospital admission to the behavioral health unit.

Findings included:

1. Review of the Medical staff bylaws of ... St Luke's Regional Medical Center (SLRMC) ...approved 9/2016, revealed in part, "Emergency Medical Treatment and Active Labor Act (EMTALA): agree to participate as an on-call physician and to respond in a timely manner when called by the emergency medicine service line to examine, evaluate and treat patients with emergency medical conditions ...."

2. Review of the policy Transfer & Emergency Examination-EMTALA, revision date 12/2015, defined and Emergency Medical Condition as follows: "Medical Psychiatric- 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."

Additionally, the EMTALA policy revealed in part, "Any individual who comes to the dedicated emergency department requesting examination or treatment for a medical condition shall be provided with a medical screening examination by qualified medical personnel to determine if an emergency medical condition exists ...within the capabilities of the SLRMC facility ...to determine whether or not an emergency medical condition exists ...individuals requesting mental health evaluation or treatment ...will receive a medical screening examination in the Emergency Department."

3. Review of on call schedules for 6 months revealed a psychiatrist listed as available for on call services every day of the month 24 hours a day, 7 days a week. The on call schedules fail to identify the psychiatrist was available for only adult psychiatric patients that present to the ED.

4. Review of the medical record revealed Patient #8, a pediatric patient, presented in the ED on 3/20/17 at 5:19 PM accompanied by police officers. Patient #8 presented with complaint of suicidal thoughts and a plan to harm others in a group home. Patient #8 stated the suicidal plan is by hanging self. Patient #8 was located by the police and brought to the ED for evaluation.

The ED physician's note, dated 3/20/17 at 5:43 PM, revealed ED Advanced Registered Nurse Practitioner (ARNP) C assessed Patient #8, a pediatric patient. ED ARNP C noted Patient #8 ran away from the group home and planned to self harm and harm another person in the group home. ED ARNP C noted Patient #8's plan to self harm as stabbing self. ED ARNP C documented Patient #8 stated, "I just want to die." The foster family reported this as typical behavior.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED ARNP C discharged Patient #8 to the group home on 3/20/17 at 7:05 PM. (The same group home Patient #8 ran away from earlier the same day.)

a. Patient # 8 present to the ED on 4/3/17 at 1:30 PM. Patient #8 presented with a stick and glass bottle and reported (he/she) ran away from the group home 1 hour ago. Patient #8 hit the glass bottle with the stick and stated (he/she) was going to cause physical harm to someone.

The ED Physician note, dated 4/3/17 at 1:45 PM revealed ED Physician P assessed Patient #8's suicidal and homicidal ideations and identified Patient #8's plan to break the glass bottle and slice (his/her) throat and others in the parking lot. Patient #8 reported being suicidal often because people are cruel. Patient #8 requested admission for "suicide treatment."

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED Physician P discharged Patient #8 on 4/3/17 at 2:11 PM to the group home. Staff from the group home plan to put Patient #8 on suicide watch. (The same group home Patient #8 ran away from prior to presenting at the ED and on 3/20/17.)

b. Patient #8 presented to the ED on 4/18/17 at 1:38 PM per ambulance with complaints of suicidal ideation.

The ED Physician note, dated 4/18/17 at 2:59 PM revealed ED Physician O assessed Patient #8's suicidal ideation. Patient #8 ran away from the group home. The patient cut the left wrist and left side of neck as deep as (he/she) could. Patient #8 stated a "creepy" man forced (him/her) to have sex and use marijuana.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED Physician O ordered antibiotic therapy and discharged Patient #8 to the group home on 4/18/17 at 5:32 PM. (The same group home Patient #8 ran away from on 3/20/17, 4/3/17 and 4/18/17.)

c. Patient #8 presented to the ED on 4/26/17 at 8:51 AM with police escort with a complaint of suicidal ideation.

A nursing note dated 4/26/17 at 9:27 AM revealed ED Staff S, Care Coordinator, documented group home staff discovered Patient #8 with underwear tied around the neck to self harm. Patient #8 attempted to bite group home staff when attempted to redirect. Patient #8 wants to die because no one listens. Patient #8 received a 10 day discharge notice from the group home scheduled to be up on 4/29/17. The group home plans to discharge to a shelter if alternative placement is not found. The ED Physician note, dated 4/26/17 at 9:27 AM revealed ED Physician O assessed Patient #8's suicidal complaints. ED Physician O's assessment revealed Patient #8's plan to self harm to hang or stab self. Patient #8 admitted a history of "cutting" (self harm by cutting self with a sharp object).

Staff from the group home reported Patient #8 has a history of running away from the group home and getting into "situations with older men." Group home staff reported Patient #8's behavior worsened over the past several weeks. Patient #8 requested placement in a locked facility for treatment so (he/she) can't run away.

ED Physician O's assessment revealed linear marks around Patient #8's neck and superficial linear abrasions on the patient's left forearm with normal mood, affect and behavior.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

The ED Record revealed ED Staff S, Care Coordinator, phoned various acute care hospitals in attempt to find placement in a pediatric psychiatric facility and was unable to locate placement.

ED Physician discharged Patient #8 to the group home on 4/26/17 at 3:51 PM. (The same group home Patient #8 ran away from prior to presenting to the ED on 4/26/17, 4/20/17, 4/3/17 and 3/20/17.)

Patient #8 presented to the ED 4 times in approximately 5 weeks with a suicidal plan and/or attempt and discharged to a group home. The patient's ED record failed to include a psychiatric evaluation to evaluate the patient's psychiatric emergency.

Please refer to A 2406 for additional information.

5. Review of the medical record revealed Patient #4, a 46 year old, presented in the ED on 8/19/17 at 3:35 PM with complaints of black outs and increased anger.

The ED Physician's note, dated as date of service provided 8/20/2017 at 6:07 PM for an 8/19/17 ED visit, revealed ARNP C's medical screening examination assessed Patient #4's mood as anxious, affect is angry and agitated. The ED Physician's note included information regarding Patient #4's recent hospitalization for the same concerns (blackout and agitation).

ED ARNP C documented consultation with Patient #4's Psychiatric ARNP D and ED ARNP C discharged Patient #4 following and arranged appointment in 3 days with the Psychiatric ARNP D on a Tuesday morning.
Psychiatric ARNP D stated ED ARNP C discharged Patient #4 prior to consultation.

Patient #4's ED record failed to include evidence of a psychiatric evaluation prior to discharge.

Please refer to A 2406 for additional information.

Based on review of documentation, staff interviews, and hospital policy the hospital's Emergency Department (ED) staff failed to provide a medical screening examination(MSE) and stabilizing treatment within the hospital's capability and capacity prior to discharging 2 of 26 sampled patients that presented to the ED (Patient #4 and #8). The Acute Care Hospital reported an average of 2,686 ED patients per month.

Failure to provide medical screening examination and treatment within the hospital's capabilities for a patient with an emergency medical condition (EMC) could potentially delay the appropriate treatment for the patient and result in further complications, including death.

Findings include:

1. Review of the Medical staff bylaws of ... St Luke's Regional Medical Center (SLRMC) ...approved 9/28/2016, revealed in part, "Emergency Medical Treatment and Active Labor Act (EMTALA): agree to participate as an on-call physician and to respond in a timely manner when called by the emergency medicine service line to examine, evaluate and treat patients with emergency medical conditions ...."

2. Review of the policy Transfer & Emergency Examination-EMTALA, revision date 12/2015, defined and Emergency Medical Condition as follows: "Medical Psychiatric- 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."

Additionally, the EMTALA policy revealed in part, "Any individual who comes to the dedicated emergency department requesting examination or treatment for a medical condition shall be provided with a medical screening examination by qualified medical personnel to determine if an emergency medical condition exists ...within the capabilities of the SLRMC facility ...to determine whether or not an emergency medical condition exists ...individuals requesting mental health evaluation or treatment ...will receive a medical screening examination in the Emergency Department."

3. Review of on call schedules for 6 months revealed a psychiatrist listed as available for on call services every day of the month 24 hours a day, 7 days a week. The on call schedules failed to identify the psychiatrist as only available for adult psychiatric patients that present to the ED.

4. Review of Patient #4's medical record revealed the following:

a. Patient #4, a 46 year old, presented in the ED on 8/19/17 at 3:35 PM with complaints of black outs and increased anger.

b. The ED Physician's note, documented as date of service provided 8/20/2017 at 6:07 PM for an 8/19/17 ED visit, revealed Advanced Registered Nurse Practitioner (ARNP) C's medical screening examination (MSE) assessed Patient #4's mood as anxious, affect is angry and agitated. The patient does not have suicidal or homicidal plans.
The ED Physician's note identified Patient #4's recent hospitalization for the same concerns (blackout and agitation).

ED ARNP C assessed Patient #4's diagnostic tests (assessment of the patient's blood) are unremarkable.

The urine drug screen dated 8/20/17 revealed presumptive positive for amphetamines and benzodiazepines related to the patient's medications.

ED ARNP C documented consultation with Patient #4's Psychiatric ARNP D. ED ARNP C discharged Patient #4 and arranged an appointment in 3 days with Psychiatric ARNP D on Tuesday morning.

Patient #4 became agitated and demanded hospital admission upon notification of discharge. ED ARNP C encouraged Patient #4 find coping mechanisms for agitation, and discharged the patient.

Patient #4's ED record failed to include evidence of a psychiatric evaluation prior to discharge.

c. During an interview on 8/30/17 at 1:56 PM ED Staff F, care coordinator (CC) and social worker, stated Patient #4's ED visit on 8/19/17 was actually the fourth visit that month. Patient #4 could not recall things and was just discharged from the hospital's behavioral health unit (BHU). ED Staff F confirmed Patient #4 reported no current suicidal ideation, but the thoughts are always there. The patient did not have a plan for suicide.

ED Staff F stated Patient #4 returned the following day (8/20/17) and everything changed. Patient #4 felt worse and was not happy with ED ARNP C. Patient #4 wanted hospital admission for help with psychiatric concerns.

ED Staff F stated on 8/19/17 Patient #4 was not erratic or attention seeking. ED Staff F felt there was really something going on. ED Staff F felt ED ARNP C brushed Patient #4 off at a time the patient needed someone to advocate for (him/her). ED Staff F stated there was a bit of confrontation with ED ARNP C because he felt Patient #4 did not meet admission criteria due to a lack of harm to self or others.

ED Staff F stated she documented Patient #4's statement about the thoughts of suicide are always present. She thought ED physicians reviewed her notes, and knew on 8/19/17 ED ARNP C was not going to admit Patient #4.

ED Staff F stated when Patient #4 returned on 8/20/17 the appearance changed. Patient #4 had a sad demeanor rather than angry on 8/19/17. Patient #4 appeared in disarray with red eyes and looked defeated.

ED Staff F felt the 8/19/17 ED visit was Patient #4's cry for help. The patient was able to think rationally because (he/she) knew about a memory lapse and had missing days. Patient #4 knew (he/she) was treated badly by ED ARNP C.

d. During an interview on 8/22/17 at 11:10 AM Patient #4 stated on Saturday (8/19/17) I came to the ED because the week prior, I was hospitalized for blackout. The doctor in the ED, ED ARNP C, said mental health can be controlled by wishing it away. Patient #4 did not agree with that statement.

Patient #4 thought about attempting suicide by taking (his/her) sleeping pills, and instead called the police department. The police department arrived and spoke with the patient, then brought the patient to the ED. Patient #4 stated the same ED doctor (ED ARNP C) asked if this was a game because I was angry about not being admitted the day before. Patient #4 stated (he/she) was not, but was mad regarding the "wish away" mental health comment. Patient #4 stated if (he/she) really wanted hospitalized on 8/19/17 (he/she) could have gone to the other acute care hospital in town and simply say I'm suicidal.

Patient #4 stated ED ARNP C did not spend time or respect my mental health issues, and asked if it was a game.

Patient #4 stated the prior hospitalization in the behavioral health unit included instructions to follow up appointment with neurology for an EEG (examination of brain waves). Patient #4 did not have transportation and did not go to the neurology appointment.

e. During an interview on 8/29/17 at 3:35 PM ED ARNP C stated he knows Patient #4 well, and did not say you can think away mental illness. Instead, ED ARNP C informed Patient #4 you can control anger. Patient #4 apologized to ED ARNP C a few days ago. (Patient #4 filed a formal complaint against ED ARNP C's behavior during the 8/19/17 ED visit.)

ED ARNP C stated Patient #4 reported concerns regarding anger outbursts and did not understand them. ED ARNP C informed Patient #4 you can control anger issues. Patient #4 related anger to bipolar (depressive disorder). ED ARNP C stated coping mechanisms are needed for bipolar concerns.
ED ARNP C stated Patient #4 became angry because of planned discharge and demanded admission to the hospital. ED ARNP C was aware Patient #4 was hospitalized 1 week prior for the same concerns (blackouts). Patient #4 did not have suicidal or homicidal ideations, so I discharged (him/her).

ED ARNP C stated he attempted consultation with Psychiatric ARNP D, Patient #4's, however Psychiatric ARNP D did not answer the phone call. ED ARNP C contacted ED Physician E, who supervises ED ARNP C.

f. During an interview on 8/31/17 at 2:27 PM, ED Physician E stated Patient #4 really did not want to be admitted to the hospital. A friend convinced (him/her) to come to ED to get a hold on things. Patient #4 had a lack of memory for hours. The physician wanted to determine the medications.

Patient #4 informed ED Physician E (he/she) ran out of some medications. ED Physician E was not certain if Patient #4 routinely took medications appropriately.
ED Physician E stated he is a family physician and faculty for several universities and does not prescribe psychiatric medications. Typically he has a psychiatrist consult for psychiatric concerns, much like other specialties.

g. During an interview on 8/30/17 at 9:56 AM Psychiatric ARNP D, stated on 8/19/17 she had a voice message from ED ARNP C. ED ARNP C discharged Patient #4 before ARNP D returned the phone call. Specific times were not immediately available.

ARNP D stated ED ARNP C did contact me regarding Patient #4. ED ARNP C provided information regarding the ED visit and stated he did not feel Patient #4 met admission criteria because Patient #4 was tracking appropriately.
ARNP D follows Patient #4. Patient #4 had memory lapses for some time and was recently hospitalized. Behavior health unit staff made phone calls related to Patient #4's psychiatric concerns. The concerns were validated. The most recent hospitalization included discharge plans for a neurology consult and EEG to determine if the patient had seizures related to the memory lapse.

Patient #4 missed the neurology appointment related to a lack of transportation to the neurology office. ARNP D stated they scheduled the neurology appointment to determine if Patient #4 had seizures related to high doses of a medication used by Patient #4.

Patient #4 reported a complaint regarding ED ARNP C to ARNP D. ARNP D stated there were verified concerns regarding Patient #4's memory lapses resulting in dangerous tasks such as barbecuing in the living room, however based on ED ARNP C's assessment (not at risk to self/others, tracking well, etc) the patient may not meet admission criteria.

7. Review of Patient #8's medical record revealed the following:

a. Patient #8, a pediatric patient, presented in the ED on 3/20/17 at 5:19 PM accompanied by police officers. Patient #8 presented with complaint of suicidal thoughts and a plan to harm others in a group home. Patient #8 stated the suicidal plan is by hanging self. Police located the patient and brought to the ED for evaluation.

b. The ED physician's note, dated 3/20/17 at 5:43 PM, revealed ED ARNP C assessed Patient #8, a pediatric patient. ED ARNP C noted Patient #8 ran away from the group home and planned to self harm and harm another person in the group home. ED ARNP C noted Patient #8's plan to self harm as stabbing self. ED ARNP C documented Patient #8 stated, "I just want to die." The foster family reported this as typical behavior.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED ARNP C discharged Patient #8 to the group home on 3/20/17 at 7:05 PM. (The same group home Patient #8 ran away from earlier the same day.)

c. Patient # 8 present to the ED on 4/3/17 at 1:30 PM. Patient #8 presented with a stick and glass bottle and reported (he/she) ran away from the group home 1 hour ago. Patient #8 hit the glass bottle with the stick and stated (he/she) was going to cause physical harm to someone.

d. The ED Physician note, dated 4/3/17 at 1:45 PM revealed ED Physician P assessed Patient #8's suicidal and homicidal ideations. Patient #8's plan to self harm break the glass bottle and slice (his/her) throat and others in the parking lot. Patient #8 reported is suicidal often because people are cruel and requested admission for "suicide treatment." Patient #8 reported rib pain, however did not fall or sustain an injury.

ED Physician P's physical examination revealed Patient #8 did not have a wound and appeared anxious.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED Physician discharged Patient #8 on 4/3/17 at 2:11 PM to the group home. Staff from the group home plan to put Patient #8 on suicide watch. (The same group home Patient #8 ran away from prior to presenting at the ED and on 3/20/17.)

e. Patient #8 presented to the ED on 4/18/17 at 1:38 PM per ambulance with complaints of suicidal ideation.

f. The ED Physician note, dated 4/18/17 at 2:59 PM revealed ED Physician O assessed Patient #8's suicidal ideation. Patient #8 ran away from the group home. The patient cut the left wrist and left side of neck as deep as (he/she) could. Patient #8 stated a "creepy" man forced (him/her) to have sex and use marijuana.

ED Physician O's assessment revealed a superficial cut on the patient's left wrist and neck, flat affect and not tearful.

A urine drug test dated 4/18/17 at 3:05 PM revealed Patient #8 negative for cannabis. The medical record included additional diagnostic tests and a Sexual Assault Nurse Examination (SANE).

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

ED Physician O ordered antibiotic therapy and discharged Patient #8 to the group home on 4/18/17 at 5:32 PM. (The same group home Patient #8 ran away from on 3/20/17, 4/3/17 and 4/18/17.)

g. Patient #8 presented to the ED on 4/26/17 at 8:51 AM with police escort with a complaint of suicidal ideation.

h. A nursing note dated 4/26/17 at 9:27 AM revealed ED Staff S, Care Coordinator, documented group home staff discovered Patient #8 with underwear tied around the neck to self harm. Patient #8 attempted to bite group home staff when attempted to redirect. Patient #8 wants to die because no one listens. Patient #8 received a 10 day discharge notice from the group home which is up on 4/29/17. The group home plans to discharge to a shelter if alternative placement is not found.

i. The ED Physician note, dated 4/26/17 at 9:27 AM revealed ED Physician O assessed Patient #8's suicidal complaints. ED Physician O's assessment revealed Patient #8's plan to self harm to hang or stab self. Patient #8 admitted a history of "cutting" (self harm by cutting self with a sharp object).

Staff from the group home reported Patient #8 has a history of running away from the group home and getting into "situations with older men." Group home staff reported Patient #8's behavior worsened over the past several weeks. Patient #8 requested placement in a locked facility for treatment so (he/she) can't run away.

ED Physician O's assessment revealed linear marks around Patient #8's neck and superficial linear abrasions on the patient's left forearm with normal mood, affect and behavior.

Patient #8's ED record failed to include evidence of a psychiatric consultation or evaluation.

The ED Record revealed ED Staff S, Care Coordinator, phoned various acute care hospitals in attempt to find placement in a pediatric psychiatric facility and was unable to locate placement.
j. A nursing note dated 4/26/17 at 2:54 PM revealed ED Staff S contacted Patient #8's Department of Human Services (DHS) case manager. DHS staff did not think the group home would accept Patient #8 because the patient required a higher level of care. ED Staff S informed DHS staff Patient #8's status is no different than prior ED visits and the group home accepted the patient at time of discharge. ED Staff S documented, we at (facility) are "doing DHS and the (group home) a favor by seeking placement" for Patient #8. ED Staff S directed DHS continue to seek placement and ED Physician O directed Patient #8 discharge in stable condition. ED Staff S noted the patient's involuntary discharge is Saturday, 4/29/17

k. ED Physician discharged Patient #8 to the group home on 4/26/17 at 3:51 PM. (The same group home Patient #8 ran away from prior to presenting to the ED on 4/26/17, 4/20/17, 4/3/17 and 3/20/17.)

l. During an interview on 9/6/17 at 8:34 AM ED Staff S stated she is a registered nurse (RN) and social worker. ED Staff S stated her job is to ensure appropriate services are in place for ED patients and set up services if needed. Additionally any patient that presents to the ED 12 times in 1 year gets a special care plan to "help them feel better" so the patient doesn't need to return to the ED so frequently.

ED Staff S had not seen a psychiatrist in the ED before. She stated the facility utilizes telehealth services for patients that are admitted to the behavioral health unit and for consultation by the ED Physician. The telehealth machine is not used in the ED, only the phone for consultation.

ED Staff S recalled Patient #8, and stated Patient #8 presented for numerous things such as mood disorder, assaulted while a run away, and suicidal. ED Staff S stated the patient had a suicide plan. Patient #8 required suicide watch when returned to the group home.

ED Staff S stated a patient that is suicidal and has a plan does not necessarily require inpatient treatment. It depends on what is going on with the patient. Patient #8 resided in the group home because of a history of... ED Staff S stopped and stated she could not recall if Patient #8 had a history of suicide attempts.

ED Staff S stated on 4/26/17 the DHS wanted Patient #8 placed quicker. ED Staff S stated Patient #8 required longer term placement and requested we (facility staff) look for placement.

ED Staff S stated Patient #8 was "baseline" on 4/26/17 ED visit. ED Staff S clarified "baseline" to mean Patient #8 reported the "same complaints as always" with no change in behavior, so the patient discharged to the group home for 1:1 care. ED Staff S stated this is the same group home Patient #8 ran away from before.

ED Staff S reviewed her documentation. She stated my thought was Patient #8 tried to self harm but that wasn't really intended to harm (his/herself). ED Staff S stated she was aware Patient #8 tied underwear around the neck and stated intended to self harm, just as the cutting. ED Staff S stated Patient #8 likes to come to the ED to have additional people around related to the mood disorder.

ED Staff S reviewed Patient #8's ED visits on 3/20/17, 4/3/17, 4/18/17 and 4/26/17. ED Staff S stated each time a patient presents to the ED, they are assessed. ED Staff S stated she did not see a change in Patient #8's behavior. (3/20/17 presents as runaway with suicidal ideation and a plan, 4/3/17 presents as runaway with suicide and homicidal ideation, a plan and threats, 4/18/17 presents as a runaway with suicidal threats, a plan, with cuts on the arm/neck and forced sexual activity, and 4/26/17 presents after self harm by strangulation and injured staff that attempted to stop the suicide attempt). ED Staff S stated Patient #8 never really intended to self harm. She thought even staff at the group home understood Patient #8 required long term care. Psychiatric care in an acute setting would not be effective.

ED Staff S stated a suicide attempt is an acute medical condition. ED Staff again stated, yes she did DHS and the group home a favor when seeking inpatient treatment because it's actually the group home's responsibility to find placement. We tried to help them out with placement.

m. During an interview on 9/6/17 at 2:30 PM ED ARNP C recalled Patient #8. ED ARNP C determined Patient #8 stable for discharge to the group home because the group home is a safe place. The group home staff provides supervision.

n. During an interview on 9/7/17 at 6:10 AM ED Physician O recalled Patient #8 in the ED after running away from the group home. ED Physician O recalled Patient #8's diagnoses included borderline personality disorder and attention seeking behaviors. ED Physician O stated most of Patient #8's attempts were "fairly superficial."

ED Physician O stated typically if a suicidal patient presents to the ED and ED staff are unable to find placement, the patient is held in the ED until placement is located. ED Physician O stated ED staff held Patient #8 quite awhile and checked options with the DHS worker. The group home always accepted Patient #8 before but the patient didn't follow their treatment plan and received a 10 day involuntary discharge.

Following the 4/26/17 suicide attempt with underwear tied around the neck, ED Physician O stated you can make gestures, but it becomes a judgement call at times. There is a risk with some patients after several attempts even after inpatient therapy. Patients with borderline personality disorder with attention seeking behaviors do not always require inpatient therapy depending upon the severity of self harm attempts.

ED Physician O stated cutting yourself, wrapping things around your neck can be pleas for help but, at the same time, not lethal.

ED Physician O stated ED Staff S has behavioral health background. Patient #8 presented similar to the prior ED visits.

ED Physician O did not request a psychiatric consult because Patient #8 would be discharged from the group home. ED Physician O stated there are some psychiatric emergencies, and threaten life. Generally the feeling is fairly low threshold for admission for patients with suicidal or homicidal ideations.

8. During an interview on 9/6/17 at 5:10 PM Psychiatrist Q stated his group provides on call services after 5:00 PM for the ED. On call duty is shared by his group and another local psychiatric group.

Psychiatrist Q and his partners provide psychiatric care (consult) to established patients only as a result of changes made by the hospital approximately 3 years ago and a decision to utilize telehealth. The hospital utilizes telehealth for all patients that present to the ED and are not "attached" to a local psychiatrist and for all inpatient behavioral health patients, with the exception of Psychiatrist Q's established patients.

All patients, established or unattached to a current psychiatrist, are able to receive a psychiatric evaluation or consult by a psychiatrist 24 hours per day, 7 days per week. Psychiatrist Q stated his group provides psychiatric evaluations for pediatric psychiatric concerns. Psychiatrist Q thought the telehealth providers were able to provide pediatric psychiatric consultations.

9. Observation on 9/7/17 at 8:30 AM with the Behavioral Nurse Manager revealed the telehealth machine in a separate room near the Behavioral Health Unit. The Behavioral Nurse Manager thought the telehealth psychiatrist could evaluate pediatric psychiatric patients.

She was not aware of a time ED staff requested a telehealth psychiatric evaluation. ED Physicians are trained and know when to request a psychiatric evaluation.

The telehealth psychiatrist is only available weekdays until 5:00 PM. After 5:00 PM, local psychiatrists are scheduled as available for on call services.

10. During an interview on 9/7/17 at 6:10 AM ED Physician O, ED Medical Director, stated typically the ED Physicians determine if the patient has an emergency psychiatric condition and orders a court order.

ED Physician O stated the ED has a list of on call physicians, which include on call psychiatrists. The ED Physician is the only qualified medical professional.

11. During an interview on 9/7/17 at 10:44 AM the Medical Director of the Behavioral Health Unit stated the facility has a psychiatrist available on call for the facility until 5:00 PM. The psychiatrist can be physician or mid-level provider (physician's assistant or ARNP).

After 5:00 PM a local provider is available on call for psychiatric consults. The telehealth services were not available for pediatric patients, however if a pediatric patient is part of an established local group, the on call provider may address that or transfer a pediatric patient to another facility.