HospitalInspections.org

Based on facility policy review, medical staff rules and regulations, police report review, ambulance report review, record review, video review, electronic document review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were provided an appropriate and ongoing medical and psychiatric screening examination (MSE) within the hospital's capabilities to ensure patients were not experiencing psychiatric issues and were safe to be discharged to home and self-care for 1 of 20 (Patient #1) sampled patients presenting to the ED.

The findings included:

Refer to A2406

Based on facility policy review, medical staff rules and regulations, police report review, ambulance report review, record review, video review, electronic documentation review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were provided an appropriate and ongoing medical and psychiatric screening examination (MSE) within the hospital's capabilities to ensure patients were not experiencing psychiatric issues and were safe to be discharged to home and self-care for 1 of 20 (Patient #1) sampled patients presenting to the ED.

The findings included:

1. Review of Hospital #2's Evaluation And Transfer of Patients With Emergency Medical Conditions policy revealed, "...Medical Screening ...[Name of Hospital] complies with federal statutes and regulations regarding the screening and transfer of patients with emergency medical conditions...does not discriminate based on race, religion, handicap, disability, national origin or financial status ...Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions...The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available at [Name of Hospital's] emergency department ...Performs triage evaluation. If patient is classified as urgent or emergent, provides further evaluation and stabilizing treatment ... Performs indicated evaluation and stabilizing treatment ...Follows regular medical screening procedures".

Review of Hospital #2's Psychiatric Evaluation Plan policy revealed, "...Patients presenting to the Emergency Department (ED) with psychiatric and/or drug/substance abuse complaints receives a medical screening exam, behavioral health assessment, stabilizing treatment, and medical clearance prior to transfer to an appropriate facility...The Physician assesses the patient for medical conditions and identifies the need for additional psychiatric assessment. When indicated, the physician requests psychiatric assessment coverage (available 24 hours per day) by contacting the Consulting Psychiatric Facility."

Review of Hospital #2's Discharge From The Emergency Department Policy revealed, " ...After all [discharge] instructions have been explained to the patient and the patient has expressed understanding of all instructions, the discharge instruction sheet is signed by the patient and the nurse providing the instructions ...Patients discharged from the Emergency Department are given a copy of the completed After Visit summary..."

2. Review of Hospital #2's Medical Staff Rules and Regulations revealed, "...an emergency condition is a medical condition manifesting acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy, or to result in impairment of bodily functions...When an individual presents to the emergency department requesting examination or treatment of a medical condition, the medical screening examination is based on the individual's presenting complaint and is typically provided by a physician or a Nurse Practitioner or Certified Assistant under the direct supervision of the emergency department physician....Stabilize means to provide such medical treatment as may be necessary to assure, within reasonable medical probability that no material deterioration of the emergency condition is likely to result from or to occur during the transfer of the patient ...The term transfer means movement (including the discharge) of a patient outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly with) the hospital, but does not include such a movement of a patient who has been declared dead, or leaves the facility without permission of any such person..."

3. Review of a Crisis Assessment Center (CAC) evaluation dated 12/24/2020 conducted by an affiliate CAC located in Hospital #1 (a psychiatric hospital) revealed Patient #1 received a Psychosocial evaluation via telecommunications and was referred by his lawyer for the Psychosocial Evaluation. The evaluation revealed, "The client (Patient #1) reported that he is hearing voices, seeing things, and does play games with people in his head. The client's sister has been granted Conservatorship over the client...client reported that he has had suicidal ideations in the past...recently diagnosed with Dementia...was prescribed Quetiapine for treating Dementia but it doesn't work...he never receives any medication for Schizophrenia ...never received treatment for his mental illness in the past....The client's sister reported he was hit by a car [while living in California] ...He [Patient #1] was having problem [problems] just wondering [wandering] on persons' properties..."
The patient was diagnosed with Schizophrenia, Unspecified Dementia with Behavioral Disturbance, Hypertension and Hyperchylomicronemia".

4. Review of Patient #1's hospitalization history obtained by Hospital #2 (an acute care hospital) revealed the following:

On 1/14/2021 Patient #1 was seen in the ED at Hospital #3 (acute care - out of State sister facility of Hospital #2) with the complaints of Hallucinations and Psychosis. Patient #1's sister reported that she had taken care of Patient #1 for the past 4 (four) days and it was becoming difficult. The sister reported Patient #1 was experiencing visual and auditory hallucinations, was pulling the curtains off the rods, and pulling up tiles off the floor, and destroying things.

Review of the 1/14/2021 ED Provider Notes at Hospital #3 revealed the Physician documented Patient #1 had a history of Schizophrenia, Hallucinations and Psychosis, and the patient's sister reported the patient isn't taking medications. Patient #1 reported the medications were too expensive and he could not afford them. The patient was administered oral Ativan 1 milligram in the ED.

Review of the 1/14/2021 Psychiatric Evaluation performed at Hospital #3 revealed Patient #1 was homeless, indigent and tested positive for Opiates. Patient #1 often wanders off and brought home by strangers. Patient #1's sister reported the patient threatened "to do something to me" if he wouldn't go to jail. The sister reported Patient #1 had recently started being seen by a Psychiatric Service and was scheduled to be seen again on 1/28/2021. The sister reported she does not feel safe with Patient #1 and is required to lock herself in her room when Patient #1 is at her house. The psychiatric evaluation documented Patient #1 seemed paranoid and his mood was irritable. Hospital #3 transferred Patient #1 to an inpatient psychiatric hospital (Hospital #4) for admission and treatment of psychiatric issues.
(NOTE: Surveyor attempts to obtain the medical records at Hospital #4 for Patient #1 were unsuccessful due to the hospital being out of State).

4. Review of a police report dated 1/22/2021 at 6:52 PM revealed the local police department was called to Patient #1's relative's house due to the patient experiencing behaviors. The police report documented Patient #1's relative reported that the patient went outside and urinated in front of the apartment. Patient #1 stated he would go somewhere and "die" if they didn't take him somewhere. The police transported Patient #1 to the CAC at Hospital #1 (a psychiatric hospital).

5. Review of the CAC 1/22/2021 Crisis Assessment, that was completed by a Nurse Practitioner (NP) revealed, " ...Pt [Patient #1] presents as poor historian as evidenced by Dementia like symptoms ...Pt [Patient #1] presents at risk of harm/danger to self/others as evidenced by Pt out of touch with reality/inadequate impulse control. Currently, Pt is unable to reliably contract for safety as evidenced by poor insight/poor judgement/responding to internal stimuli. Currently, Pt meets criteria for level of care as evidence a lack of intervention would contribute to further decompensation ...Pt is to remain at CAC this evening for safety reasons/until we appropriate transition conducive to safety, and stabilization."

The 1/22/2021 CAC Crisis Assessment further revealed there was confusion about where Patient #1 would live post discharge from inpatient care. The Crisis Assessment revealed Adult Protective Services [APS] should be contacted to assist Patient #1. Patient #1 was kept in observation overnight at the CAC on 1/22/2021 for safety reasons, and " ...Sister also reported that Pt has been like this for the past five years ...Sister reports that Pt wonders [wanders] and needs to be in a locked facility ..."
The CAC documented they spoke to APS and APS suggested taking Patient #1 to a hospital. Emergency Medical Services (EMS) was contacted to transport Patient #1 to Hospital #2.

6. Review of the EMS report dated 1/23/2021 at 3:10 PM revealed EMS had picked Patient #1 up from the CAC at Hospital #1 [a psychiatric hospital] and transported the patient to Hospital #2 [an acute care hospital] for "Medical Clearance". The EMS report revealed the complaint reported was "Psychiatric Problem/Abnormal Behavior/Suicide Attempt ..."

EMS documented they provided a copy of the CAC Assessment to the ED nurse at Hospital #2 and the assessment was stamped in acknowledgement of receipt by Hospital #2.

7. Record of the medical record from Hospital #2 revealed Patient #1 had diagnoses which included Schizophrenia and Unspecified Dementia with Behavioral Disturbance.

Review of Hospital #2's "Patient Demographics" form revealed, "Patient has no active insurance coverage on file for 1/23/2021."

Review of Hospital #2's ED "Patient Care Timeline" revealed Patient #1 presented to the ED via EMS on 1/23/2021 at 3:34 PM.

Patient #1's triage was conducted at 3:41 PM by LPN #1 with the Chief Complaint of "Other (medical clearance)."

Patient #1 was placed in ED Room 41 at 3:42 PM, was assigned to Physician #1 at 3:43 PM, and assigned to Registered Nurse (RN) #1 at 3:48 PM.

RN #1 conducted a Suicide Risk assessment at 3:56 PM and documented "No" Patient #1 had not wished he was dead in the last month, to having thoughts of ending his life in the last month and had not done anything to end his life during his lifetime.
RN #1 documented Patient #1's appearance was, "WDL [within defined limits]."
There was no documentation the RN reviewed the Crisis Assessment from the CAC that was provided by EMS.

Review of Hospital #2's ED Physician notes conducted by Physician #1 dated 1/23/2021 at 3:44 PM revealed, "[Patient #1] is a 58 y.o. [year old] Male ...significant for schizophrenia who presents to the ED via EMS from the Crisis for medical clearance for admission to [Hospital #1]".
Physician #1 documented, "The history is provided by the patient and the EMS personnel...Past Medical History...Schizophrenia..."
Physician #1 documented, "He [Patient #1] is agitated on arrival but denies visual and auditory hallucinations. Laboratory analysis was negative for any acute hematologic or metabolic derangements. He denies any suicidal or homicidal ideation there is no evidence of any medical emergency. He will be discharged for outpatient psychiatric follow-up. [Hospital #1] was contacted and states that he was evaluated already in the facility and was discharged and that there was no indication for psychiatric admission." There was no documentation ED Physician #1 had contacted Hospital #1. There was no documentation ED Physician #1 had contacted the CAC Nurse Practitioner who conducted the Crisis assessment at the CAC regarding Patient #1. There was no documentation ED Physician #1 reviewed the CAC Crisis Assessment that was delivered to Hospital #2's ED along with Patient #1 via EMS.
There was no documentation the patient's agitation was further addressed or treated as needed.

Review of Hospital #2's ED "Patient Care Timeline" report dated 1/23/2021 at 4:41 PM revealed "ED Disposition set to Discharge." At 4:42 PM "ED After Visit Summary" was printed and at 4:42 PM, "Patient Ready to Go."

On 1/23/2021 at 6:02 PM revealed RN #1 documented Patient #1 remained in the ED waiting area and, "waiting on [CAC] nurse to call back.

On 1/23/2021 at 6:55 PM RN #1 documented the Shift Supervisor/Social Worker (SW) at the Crisis Center was contacted and, "Per [CAC], patient has been cleared and is not to be admitted to [Hospital #1]". RN #1 documented Patient #1 was neither suicidal nor homicidal and has been medically cleared per Physician and, "pt is to be discharged home."

Review of Hospital #2's taped telephone conversation between RN #1 and the CAC shift supervisor revealed the CAC shift supervisor stated they would not accept Patient #1 back for admission because Patient #1 was homeless, and the CAC was on diversion. The CAC shift supervisor stated that it was "more of a housing thing." RN #1 asked the Crisis Center shift supervisor what a housing issue means, and the CAC shift supervisor stated, "Basically he's homeless..."

There was no documentation of further examination or assessment of Patient #1 from 4:00 PM - 7:00 PM during Patient #1's stay in Hospital #2's ED. At 7:00 PM vital signs were taken, and RN #1 documented the patient was given discharge instructions to report to a local community center in one day.

RN #1 documented at dated 1/23/2021 at 7:01 PM, "RN has called the patient's family contact to arrange transportation for the patient." There was no documentation that RN #1 actually spoke with a family member.

Patient #1 was discharged from Hospital #2's ED on 1/23/2021 at 7:01 PM. RN #1 documented the discharge departure condition was that the patient was ambulatory, and the departure mode was "By self."

Patient #1 remained outside Hospital #2 for over an hour. There was no documentation why Patient #1 remained on Hospital #2's campus for over an hour after discharge. There was no documentation Hospital #2 provided an additional assessment or screening for Patient #1 to determine if there had been a change in Patient #1's condition requiring attention.

8. Review of Hospital #2's video recording revealed the following on 1/23/2021 of Patient #1 post hospital discharge at 7:01 PM:

At 7:45 PM Patient #1 was seen outside of Hospital #2's ED and walking towards the street escorted by a local police officer and followed by a police vehicle driven by a second officer. Once at the street, Patient #1 was left, and the police officer got into the police car and they drove away.

At 7:58 PM Patient #1 was observed wearing a white blanket over his shoulders walking back towards Hospital #2's ED. Two hospital security guards walked out to meet Patient #1 and stopped the patient on the sidewalk, talked with the patient and prevented the patient from entering Hospital #2's ED.

At 8:08 PM a police car was seen driving back onto Hospital #2's property. Two police officers got out of the police car, walked towards Patient #1 and the hospital Security Guards who were standing on the sidewalk outside Hospital #2's ED and began talking to Hospital #2's security guards. (No audio).

At 8:13 PM Hospital #2's Security Guard walks back towards Hospital #2's ED entrance and Patient #1 was assisted into the police car and driven off Hospital #2's property.

Based on surveyor interview with a local police detective, Patient #1 was transported by the local police from Hospital #2 to Hospital #3.

9. Review of Hospital #3's video recording of the outside area of the hospital revealed Patient #1 walking around outside Hospital #3. There is no documentation Patient #1 presented inside Hospital #3's ED on 1/23/2021 after being dropped off there by the local police department.

According to an interview with a local police detective overseeing missing persons, Patient #1 was driven to the ED at Hospital #5 (an acute care hospital) and dropped off on Hospital #5's campus. Patient #1 has not been seen since then and is considered a missing person. The local police department has an ongoing active investigation for Patient #1.

10. During an interview on 2/3/2021 at 2:10 PM, RN #1 confirmed she was told by the Shift Supervisor/SW at the CAC that they were on diversion. RN #1 stated, "I went to find [ED Physician #1] and told him [Hospital #1] was not accepting him [Patient #1] and asked what's the plan for him [Patient #1]. He [ED Physician #1] said "we would discharge him..."

RN #1 was asked if Patient #1's family had been notified of the discharge for transportation home and RN #1 stated she called a brother in an adjoining state who was the only contact listed in the medical record. RN #1 confirmed she left a voice mail on the phone number that was listed.

RN #1 was asked if she had read the CAC psychiatric evaluation that was sent with Patient #1 from the CAC, RN #1 verified she had not read the CAC psychiatric evaluation was sent with Patient #1 to the hospital.

During a telephone interview with ED Physician #1 on 2/16/2021 at 10:09 AM, ED Physician #1 was asked if he had performed a psychological assessment on Patient #1 prior to discharge and ED Physician #1 stated, "I did not because there was no indication for one. [Patient #1] was a very comfortable gentleman, very cooperative, very good insight into his medical conditions. As a board-certified emergency room physician, it's certainly within my ability to assess him for any psychiatric emergencies which we're certainly trained to do. In his case, he was a very cooperative gentleman, no overt signs of psychosis, regardless of his medical history and regardless of his psychiatric history, no auditory hallucinations, visual hallucinations, no suicidal ideation, no homicidal ideation, none of that either, and that is both on separate psychiatric assessments by myself and also by nursing".
ED Physician #1 was asked if he reviewed the paperwork sent with Patient #1 to the hospital by the CAC, and ED Physician #1 stated, "I don't recall any documentation that I reviewed, certainly nothing that would supersede my assessment of him there in the ER. I think somebody told me he was assessed 24 hours prior in [Hospital #1], but I don't recall an assessment that I reviewed that evening. Whatever assessment he had received 24 hours prior, like I said, nothing would really change my assessment right there in the emergency department of him."

During a telephone interviews on 2/8/2021 and 2/11/2021, Patient #1's Power of Attorney (POA)/sister stated Patient #1 had been discharged from a Psychiatric hospital in another State and when the patient arrived at their home, Patient #1 began pulling the curtains off the windows and the local police were called. The police detained Patient #1 and took him to the CAC at Hospital #1. The POA/sister stated she was never notified Patient #1 had been transferred to Hospital #2, and discharged ambulatory per self from Hospital #2; and had not been notified Patient #1 had been taken to Hospital #5. The POA/sister stated on 1/25/2021 she began inquiring of the whereabouts of Patient #1 and she had been informed by the local police that Patient #1 was missing.

11. Review of local news station #1's website article dated 1/28/2021 revealed the POA/sister is searching for Patient #1 who has been missing since Friday when he was admitted into Hospital #2. Patient #1's sister/POA stated Patient #1 suffered from schizophrenia.
The article documented, "[POA/sister] says [Patient #1] had an episode recently and was taken to [Hospital #2] Friday for [medical] clearance before getting placed into a mental health facility".
The article stated when Patient #1's POA/sister arrived at Hospital #2; Patient #1 wasn't there.
The article stated the POA/sister said, "They [Hospital #2] said they had discharged him to home," she said. "I said discharged him to home. Home to who? I'm home."

The article continued, the POA/sister "says the discharge nurse [at Hospital #2] told her security guards talked to [Patient #1] before walking him out to [street name]. She said the nurse told her Patient #1 "appeared to be alright."
The POA/sister stated, "I said you walked my brother out the building ...walked him up to [street name] to a bus stop and came back?" and the discharge nurse stated "Yes."
The POA/sister stated "My brother in his condition, he don't know where he is, he don't know people here, he don't know safe places, he's probably cold, I'm sure hungry ...The inhumanity of it all."
Review of local news station #2's website article dated 2/12/2021 revealed Patient #1's POA/sister "is desperate for answers".
The article stated the POA/sister said, "Each day I'm hanging on by a thread ...It was hard for me to sleep last night knowing that it was actually ice out there."
Patient #1's sister stated in the article, "My brother is very humble. My brother is a kind, easy going man," and, "Even in the throes of a mental disease, a mental illness like schizophrenia, he's still pleasant, and he did not deserve what has happened to him." Concerned about the freezing temperatures, Patient #1's sister has been canvassing downtown posting his picture. "This has created a life-or-death situation here," Patient #1's sister said.

As of Thursday, 2/18/2021 Patient #1 is still a missing person. The temperatures during much of this time have been recorded as below freezing and a record low temperature of 1-degree Fahrenheit. There have been no police leads as to the whereabouts of Patient #1.

12. On 3/3/2021 at 1:52 PM an electronic communication was received from Hospital #2's Risk Manager which stated the hospital's Security Guard had seen Patient #1 outside on the hospital's property "wrapped up in a blanket". According to the hospital Security Guard, Patient #1 asked to be taken to jail because the patient wanted somewhere warm for the night. The hospital Security Guard stated the local police arrived and offered to take Patient #1 to Hospital #5 (an acute care hospital with a psychiatric unit) and told Patient #1, "he could go there and be evaluated" and, "a least he would warm for the night". The hospital Security Guard stated Patient #1, "did not appear to be confused". The hospital's Security Guard was not a healthcare professional who could assess and evaluate patients' mental health status.

13. During a telephone interview on 3/3/2021 with Patient #1's sister, the patient's sister stated Patient #1 has not been found.