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Based on review of a 20 patient sample of emergency department medical records, review of a medical record from a receiving hospital, and interview with facility staff members, it was determined that the hospital did not comply with the provider agreement as defined in 42 CFR 489.24(b), to comply with 42 CFR 489.24.

Findings include:

1. The hospital failed to comply with 42 CFR 489.24(a) and 489. 24(c) by providing an appropriate medical screening examination to 1 patient (7) of the sample.

2. . The hospital failed to comply with 42 CFR 489.24(d)(1-3) because appropriate stabilizing treatment was not provided for 1 patient (7) of the sample.

Based on review of a patient sample of 20 medical records from ED (Emergency Department) visits, interview with a physician and hospital staff, and review of the hospital's EMTALA (Emergency Medical Treatment And Labor Act) policies, it was determined that the hospital failed to provide an appropriate medical screening examination for one of the sampled patients to determine stability prior to discharge from the hospital. The hospital did not provide stabilizing treatment or provide an appropriated transfer to a hospital for psychiatric treatment. Patient identifier 7.

Findings include:

MEDICAL RECORD REVIEW FOR THE FIRST EMERGENCY DEPARTMENT VISIT

Review of patient 7's medical record revealed that this 63 year-old female presented at the ED on 9/29/11 at 8:19 AM, from the jail in police custody.

1. The medical record included a document dated 9/29/11, titled: "Emergency Application For Involuntary Commitment Without Certification" also known as a pink slip. The form documented that patient 7 was observed by a police officer to engage in conduct which led the officer to believe that there was probable cause that patient 7 was mentally ill and that there was substantial likelihood of serious harm to herself or others. The patient was taken into protective custody for the circumstances of being substantially impaired and the need to rule out psychosis versus schizophrenia. Patient 7 was described as being unable to take care of herself due to being gravely mentally ill. Patient 7 was also described as not having the capacity to make decisions regarding her safety. The form documented that the patient was committed to the St. Marks ER.

2. Review of the ED physician's progress notes revealed the following information:

Patient 7 arrived at the ED in police custody. The physician listed patient 7's chief complaint as "BEHAVIOR CHANGE and MEDICAL CLEARANCE and DELUSIONAL" . The physician documented that patient 7 was pink slipped. The physician documented that patient 7 had experienced situational problems due to being homeless and staying in a homeless shelter. The patient was noted to have exhibited a behavior change. The physician documented that the patient had suffered delusions. The physician documented that the patient had a place to stay at the homeless shelter, however patient 7 thought that she could not go back. The physician indicated that the nursing notes had been reviewed.

The physician documented in the section for the history and physical findings that patient 7 was cooperative and did not have poor hygiene. The physician indicated under the section titled "Psych/Neuro" that the patient was disoriented to time and exhibited altered thought processes, verbalized as loose associations and tangential thoughts. The physician indicated that the patient had no hallucinations and denied suicidal or homicidal thoughts. The physician documented that the patient did not seem to understand her illness or feel that treatment was necessary. The physician documented that the differential diagnosis was chronic schizophrenia.

The physician at 10:25 AM. documented that patient 7 was evaluated by the crisis worker who was concerned about her safety due to having delusions. "Crisis feels that the patient requires inpatient treatment for possible untreated schizophrenia. She is working on finding a bed."

At 10:39 AM., the doctor documented that the crisis worker had called a local hospital where patient 7 had received a psychiatric consult. The physician documented that the comparison with the other hospital's medical record indicated that patient 7 was at "baseline now". The patient had been camping out and staying at the shelter. The physician documented that the homeless shelter personnel were working with the patient on obtaining more permanent housing. The physician documented that patient 7 was chronically mentally ill and would not take her medication when she is discharged from the hospital. The physician indicated that she would encourage patient 7 to go to the homeless shelter that night as usual.

At 12:21 PM. the physician documented that the crisis worker spoke to the homeless shelter staff who indicated they knew the patient well. The staff member from the homeless shelter stated that they would be expecting the patient. The physician documented that the patient had a bus pass and knew how to get to the homeless shelter. The patient was discharged to the homeless shelter.

2. Review of the nursing documentation revealed the following:

The triage nurse documented that patient 7's chief complaint was "HALLUCINATIONS, DELUSIONS and BIZARRE BEHAVIOR". The triage nurse documented that patient 7 arrived hand cuffed and in police custody and was pink sheeted due to being substantially impaired. The patient was in the ED to be evaluated to rule out psychosis versus schizophrenia.

The nurse documented the following under the section titled "PHYSICAL ASSESSMENT":

Patient 7 was described as appearing anxious and disoriented to her situation. The nurse documented that patient 7's mood and affect appeared hostile. The nurse documented that patient 7's: "Behavior appears abnormal, including paranoid behaviors and having apparent visual hallucinations. The patient appears to have altered thought processes, verbalized as flights of ideas, loose associations, phobias and obsessive-compulsive ideation."

At 1:00 PM, a nurse documented that patient 7 had been cleared by the crisis worker for disposition to the homeless shelter via bus. Patient 7 refused to have her vital signs taken stating "no. no. no. You've taken enough. You're not taking anything else". Patient 7 informed the nurse: "that thing (monitor) has a serious problem. There is strawberry shortcake in it". The nurse described patient 7 as being animated and adamant that she not receive any interventions. The nurse documented that patient 7 made frequent "off the wall comments".

The medical record included documentation that the patient had documented assessments and monitoring indicating restraint use i.e. seclusion while in the ED.

At 2:42 PM the nurse documented that patient 7 was discharged with her belongings and had a bus voucher and was to go to the homeless shelter. Concerning discharge instructions the nurse documented that patient 7's ability to learn was limited due to poor comprehension. The patient was discharged ambulatory from the ED and was to catch the bus.

3. Review of a crisis worker's evaluation on 9/29/11 from 9:00 AM to 11:00 AM, revealed the following information:

The assessment documented that patient 7, a sixty three year old female, was brought to the ED from the jail by the police for delusional thoughts with impaired judgement. The portion of the assessment which documented the review of systems indicated that patient 7 was disoriented, had bizarre/inappropriate behaviors (believes she is pregnant), and was confused. Under the portion of the assessment for documentation of the patient's mental status examination it was documented that patient 7 was disheveled, cooperative, guarded, psychotic, paranoid and anxious. The crisis worker documented that patient 7 had been arrested for trespassing and was homeless. Patient 7 was documented to be at low risk of suicide or homicidal actions.

The crisis worker in the written portion of the consent documented that patient 7 was transferred from the jail on a pink sheet. The assessment indicated that patient 7 had been seen previously in August of 2011, for the same symptoms and was admitted to a local psychiatric hospital. The crisis worker documented that she was unable to obtain information about that hospitalization because the telephone on the unit was not answered. The crisis worker documented that patient 7 presented with psychotic and delusional thoughts. Patient 7 was described as being a poor historian and denied previous mental health treatment. Patient 7 was unable to tell the crisis worker any background including where she was from. The crisis worker documented that patient 7 informed her that "Miss Kitty" held the door closed last night at the homeless shelter and she was arrested for trespass. Patient 7 informed the case worker that she was a substitute teacher, pregnant and that her husband was there waiting for her. Patient 7 informed that crisis worker that the reason for her visit to the ED was pregnancy. Patient 7 informed the crisis worker that here attorney had arranged for her to be screened by the local mental health authority, but she did not show up for the appointment. The crisis worker documented that: "Pt. does meet criteria for an involuntary psychiatric admission as she is unable to maintain and function in a less restrictive environment".

4. An updated crisis worker evaluation was conducted at 11:30 AM. This was a half hour after the original assessment. The assessment included the following documentation:

The crisis worker documented that she had obtained collateral information from a psychiatric evaluation done at a local hospital. The crisis workers report did not include the date of the evaluation. The hospital where the evaluation was done was not the same one that patient 7 was admitted to in August of 2011. The crisis worker also spoke to the homeless shelter where patient 7 had been staying regarding the patient. The crisis worker stated that information from both the hospital and the homeless shelter described patient 7's behavior and thought processes were at baseline. The crisis worker documented that she spoke with patient 7 again. Patient 7 informed her that she liked the bed in the ED and they would have to call the police to remove her. Patient 7 informed the crisis worker she had missed an appointment with the shelter social worker so she could not stay there anymore. Patient 7 informed the crisis worker that she didn't want to stay at the overflow shelter. The crisis worker documented that upon receiving this information that it was her opinion that although patient 7 was severely mentally ill she was able to function and maintain in a less restrictive environment. Patient 7 posed no suicidal or homicidal ideation. The crisis worker documented that the patient did not meet the criteria for involuntary admission. Patient 7 was a low risk of self harm behavior and was to be discharged to the shelter.

The patient was discharged at 2:42 PM. with instructions to ride the bus to the homeless shelter.

MEDICAL RECORD REVIEW FOR THE SECOND EMERGENCY DEPARTMENT VISIT

The face sheet for patient 7's second ED visit indicated that she returned to the ED at 2:54 PM. This was 12 minutes after the patient had been discharged. Patient 7 was accompanied by the police who again pink slipped the patient to the hospital due to being : "a danger to herself and others. Pt is acutely psychotic. Pt. in need of inpt (inpatient) tx (treatment) and evaluation".

1. Review of the triage nurse's documentation revealed the following information:

The nurse documented that patient 7 was brought to triage by police officers. The officers reported that patient 7 was found standing in the middle of the road between the lanes of traffic. The nurse documented that patient 7 appeared anxious and was "disoriented to situation"

2. Review of the nursing progress notes revealed the following:

The nurse documented that patient 7 was placed in a hospital gown, but was still at the door waiting to go. The nurse documented that patient 7 was informed several times that she was found in the middle of the street and the police brought her back to the hospital. The nurse documented that she asked patient 7 why she didn't go to the shelter and the patient stated that she was tired of the shelter. The nurse documented that she asked patient 7 why she was in the middle of the road and the patient stated that she was tired of everything. The nurse documented that patient 7 remained in the ED until she was transferred to a psychiatric hospital by ambulance at 12:59 AM.

3. Review of the physician's documentation revealed the following information: The patient arrived at the ED accompanied by the police. The patient's chief complaint was listed as "AGITATED, DELUSIONAL and PARANOID." The physician documented that patient 7 was "found wandering". Patient 7 was described as having been angry paranoid and exhibited unusual behavior. The symptoms were described as severe. The physician documented that patient 7 had been seen earlier that day, was psychotic but not suicidal, and appeared to be at her baseline functioning. Patient 7 was discharged to the homeless shelter but now returned accompanied by the police who found her wandering. The physician documented that patient 7 returned there "due to acute exacerbation of chronic psychosis".

4. The medical record included documentation of a crisis evaluation dated 9/29/11 at 4:00 PM. The crisis worker who conducted this evaluation was not the same individual who had evaluated patient 7 previously that day. Review of the crisis worker's assessment revealed the following information:

The crisis worker documented that patient 7 had been seen in the ED that morning after spending the night in jail on a trespassing charge and had been discharged to the homeless shelter. Later patient 7 was found wandering in the middle of a busy street near the hospital. The crisis worker documented that patient 7 was returned to the ED by the police. The crisis worker documented that she was unable to assess the patient due to patient 7's inability to provide information in response to questions. The mental status examination documented that patient 7 was disheveled, guarded, hostile, paranoid, psychotic, and angry. Patient 7 was described in the mental status examination as having poor judgement and insight. The crisis worker stated that patient 7 was delusional evidenced by her belief that she was the mail order bride of the chief security guard at the hospital.

The crisis worker described patient 7 as floridly psychotic and largely unable to be assessed. The crisis worker documented that patient 7 would not respond appropriately to any questions, constantly displaying loosening of associations and flight of ideas. The crisis worker documented that patient 7 was unable to care for herself in her current mental condition and required inpatient treatment.

The medical record included an emergency application for involuntary commitment. The form was signed by the crisis worker and documented that patient 7 was confused and disoriented, arrested for trespassing, and found wandering in the middle of a busy street. Patient 7 was described as being unable to provide information about herself and was unable to maintain her safety and care for herself in her current mental condition.

Patient 7 was transferred to a psychiatric hospital for admission.

INTERVIEWS

1. A telephone interview was conducted at 12:30 PM. on 12/7/11, with the crisis worker who evaluated patient 7 during her first ED admission. The interview revealed the following information:

The crisis worker stated that the patient was pink slipped from the jail. The crisis worker stated that at first she felt that patient 7 was delusional and unable to care for herself. After calling the homeless shelter, where patient 7 had been staying she determined that patient 7 was at her baseline functioning. The shelter employee stated that patient 7 had been there the night before and was supposed to go to the overflow shelter. Patient 7 became angry and the police were called and patient 7 was arrested for trespassing. The shelter staff person informed the crisis worker that patient 7 could still come back.

The crisis worker stated that she also called a local hospital where patient 7 had recently been evaluated. The crisis worker did not know exactly when patient 7 was evaluated. She stated that patient 7 had presented there with similar symptoms. The crisis worker stated that patient 7 was released because it was determined that patient 7 did not require inpatient treatment. The crisis worker stated that the information she received from the evaluating hospital and the personal from the homeless shelter felt that patient 7 was at her baseline level of functioning.

The crisis worker stated that patient 7 presented as being street wise and able to work within the system and was aware that she was to return to the homeless shelter. The patient was informed that the shelter was expecting her and agreed to go to the shelter. The crisis worker stated that patient 7 had her own bus pass and had a card in her wallet with the shelter's address and telephone number.

The crisis worker was questioned about how the decision was made to admit or discharge psychiatric patients. She stated that it was a decision made jointly between the crisis worker and the ED physician.

The crisis worker stated she was not aware that patient 7 had returned to the hospital until the interview with the surveyor.

The crisis worker stated that when she makes decisions concerning involuntary admission of psychiatric patients she errs on the side of caution. She stated that she is wary about the validity of patients who have been sent by the jail. She has evaluated many patient's who have been pink sheeted by the jail and frequently the patients are stable and discharged from the hospital if they are not suicidal or homicidal. These patients do not meet the criteria for inpatient admission. She stated that the police will bring patients in to the ED who have been arrested and release them to the hospital. That way they are not required to stay with the patient. The crisis worker stated that the jail pink sheets patient's to the hospital as a means of dumping them because the jail staff do not want to deal with them.

2. A telephone interview was conducted with the ED physician who saw patient 7 in the ED. The physician stated that patient 7 was evaluated by the crisis worker who decided the patient needed to be admitted as an inpatient to psychiatric hospital. The physician stated that the decision to admit the patient is made by the crisis worker and she usually concurs with that decision. The physician stated that the crisis worker was going to find a bed for patient 7. The crisis worker returned and informed the physician that after making a call to a local hospital where patient 7 had recently been evaluated and the homeless shelter where patient 7 had been staying, that the patient was functioning at her baseline level. The physician stated that patient 7 had been calm, cooperative and had not given the ED any problems. The physician stated that patient 7 seemed to behave at her baseline level and did not display hallucinations or delusions while in the ED. The physician stated that patient 7 did not exhibit any suicidal or homicidal ideation. Patient 7 had a place to stay at the homeless shelter. The physician stated the patient agreed to go back to the shelter and was given a bus token to get there. The physician stated that patient 7 knew how to get there. There were no grounds to involuntarily commit patient 7. The physician stated that there was no way for her to predict that patient 7 would return to the ED.

The physician stated that patients come from the jail frequently and are evaluated and sent home. The physician stated that people who have psychiatric issues and are homeless do not like to be confined with other people and do not do well in the hospital or the jail. The patients have behaviors in jail and are pink sheeted to the hospital because the jail staff do not want to deal with them. The physician stated that these type of patients do not want to be hospitalized because of being confined in close quarters with other people. The physician stated that due to these issues and the stress patient 7's condition may have deteriorated after she was hospitalized.

The hospital failed to ensure that patient 7's psychiatric condition was stable prior to discharge. The patient was discharged on her own with instructions to catch a bus for transportation to the homeless shelter. Patient 7 had informed the physician and crisis worker that she did not believe the shelter would take her back. The patient was described as hostile, delusional and experienced hallucinations while in the ED. Patient 7 never caught the bus and was returned to the ED in the custody of the police within 15 minutes of discharge because she was wandering in traffic on a busy street near the hospital.

REVIEW OF THE RECEIVING HOSPITAL MEDICAL RECORD

Review of the medical record from the psychiatric hospital where Patient 7 was transferred revealed the following information:

Patient 7 was emergently committed to the psychiatric hospital. Review of the Certificate for Emergency Commitment, dated 9/29/11, revealed that the reason for commitment was: "Pt. is a danger to herself and others. Pt. is acutely psychotic. Pt. is in need of inpt. Tx (treatment) and Eval.

Review of the physician's discharge summary from the psychiatric hospital revealed the following:

Patient was a homeless woman with a history of psychosis who was admitted to the hospital as a transfer from the St. Marks ED on 9/30/11. The reason for admission was documented as decompensating symptoms of psychosis with inability to care for self in a less structured environment and not functioning.

The physician described the history of the present illness. Patient 7 was taken to the ED at St. Marks because she was found wandering in traffic and was delusional and paranoid. While in the hospital patient 7 was making bizarre statements and did not make sense. She had difficulty answering questions. "She did not make sense to the staff in the Emergency Department as well". Patient 7 had reportedly been living at a homeless shelter and had been agitated and uncooperative. The physician documented that on September 25 patient 7 went to a different ED and complained that she had nowhere to live. She had been hospitalized a few days prior to that but informed the physician that she refused to take medication there. The patient was paranoid on September 25 and was resistant to care at that time. Patient 7 had been living in homeless shelters and short stay hotels. Because patient 7 was unable to care for herself and was markedly psychotic she was admitted for further evaluation and treatment.

The physician documented that prior to seeing the physician the next day the patient became agitated to the point of requiring chemical sedation. Patient 7's behavior was unpredictable, disorganized and she had attempted to assault staff. Patient 7 required restraints and seclusion due to a safety concern to herself and other patients. The physician documented that the agitated behavior continued for the first several days of hospitalization and the patient required continuous 1:1 supervision.

After being in the psychiatric hospital for 34 days the physician documented that patient 7 was unable to stabilize sufficiently from a psychiatric standpoint and required ongoing evaluation and care. Patient was discharged from the psychiatric hospital to a stated facility.

Review of the patient's medical record from the receiving hospital revealed that even after 34 days in a structured, psychiatric setting the patient was not stable enough to discharge to the community and required long term commitment.

Based on review of a patient sample of 20 emergency department (ED) medical records and interview with a physician and hospital staff, it was determined that the hospital failed to provide 1 patient on the sample, with the needed medical examination and treatment required to stabilize an emergency medical condition (EMC), or to provide for transfer to another medical facility for further treatment. Patient 7 arrived in the ED accompanied by police under an involuntary hold for evaluation and treatment of psychiatric symptoms. Patient 7 was deemed stable for discharge and left the ED with instructions to go to a homeless shelter, however, patient 7's underlying medical condition (psychosis/schizophrenia) persisted. No arrangements were made for further treatment and the patient experienced an exacerbation of the EMC necessitating an immediate return to the ED in police custody.

Findings include:

MEDICAL RECORD REVIEW FOR THE FIRST EMERGENCY DEPARTMENT VISIT

Review of patient 7's medical record revealed that this 63 year-old female presented at the ED on 9/29/11 at 8:19 AM, in police custody.

1. Review of the ED physician's progress notes revealed the following information:

Patient 7 arrived at the ED in police custody. The physician listed patient 7's chief complaint as "BEHAVIOR CHANGE and MEDICAL CLEARANCE and DELUSIONAL" . The physician documented that patient 7 was pink slipped (involuntary hold upon request of law enforcement). The physician documented that the patient had a place to stay "has been staying at the shelter but thinks that she can't go back".

The physician indicated in the documentation of history and physical under the section titled "Psych/Neuro" that the patient was disoriented to time and exhibited altered thought processes, verbalized as loose associations and tangential thoughts. The physician indicated that patient 7 expressed no hallucinations and denied suicidal or homicidal thoughts. The physician documented that the patient did not seem to understand her illness or feel that treatment was necessary. The physician listed chronic schizophrenia as the differential diagnosis.

The physician documented that patient 7 was evaluated by the crisis worker who was concerned about her safety due to having delusions and needed inpatient treatment for possible untreated schizophrenia. The crisis worker was going to find a bed so patient 7 could be transferred to an inpatient facility.

The doctor documented that the crisis worker contacted a local hospital where patient 7 had recently received a psychiatric consult. The patient's condition at that time compared to the information from the previous psychiatric evaluation indicated that patient 7 was at "baseline now". The patient had been camping out and staying at the homeless shelter. The physician documented that patient 7 was chronically mentally ill and would not take her medication when not in the hospital. The physician indicated that patient 7 would be encouraged to go to the homeless shelter that night.

The physician documented that the crisis worker contacted the homeless shelter and was told by staff that they knew the patient well and would expect her return. The physician documented that the patient had a bus pass and knew how to get to the homeless shelter. The patient would be discharged to the shelter.

2. Review of the nursing documentation revealed the following:

The triage nurse documented that patient 7's chief complaint was "HALLUCINATIONS, DELUSIONS and BIZARRE BEHAVIOR". Patient 7 arrived handcuffed and in police custody. The patient was pink sheeted (involuntary commitment) to the hospital for evaluation. The patient was described as substantially impaired and was in the ED to rule out schizophrenia. The medical record documented that patient 7 was in seclusion while in the hospital based on an assessment and documented monitoring.

The nurse documented that patient 7 appeared anxious and disoriented. Patient 7's mood and affect appeared hostile. The nurse documented that patient 7's: "Behavior appears abnormal, including paranoid behaviors and having apparent visual hallucinations. The patient appears to have altered thought processes, verbalized as flights of ideas, loose associations, phobias and obsessive-compulsive ideation." At one point patient 7 informed the nurse
"that thing (monitor) has a serious problem. There is strawberry shortcake in it". The nurse documented that patient 7 made frequent "off the wall comments". The nurse documented that patient 7 had been cleared by the crisis worker for discharge to the homeless shelter via bus.

At 2:42 PM the nurse documented that patient 7 was discharged with her belongings and had a bus voucher and was instructed to go to the homeless shelter. The nurse documented that the patient walked out of the ED to catch a bus.

3. Review of a crisis worker's evaluation on 9/29/11, at 9:00 AM to 11:00 AM, revealed the following information:

The assessment documented that patient 7, was a sixty three year old female, brought to the ED from the jail because of delusional thoughts with impaired judgement. The assessment indicated that patient 7 was disoriented, confused and had bizarre/inappropriate behaviors.
The crisis worker in the written portion of the assessment documented that patient 7 had been transported from the jail on a pink sheet. The assessment indicated that the patient had been seen previously in August of 2011 for the same symptoms and was admitted to a local psychiatric hospital. Patient 7 now presented with psychotic and delusional thoughts. The crisis worker indicated that the patient was a poor historian who denied previous mental health treatment. Patient 7 was unable to provide information of where she was from. The crisis worker documented that patient 7 informed her that she was not allowed into the homeless shelter the night before and was arrested for trespassing. The crisis worker documented that patient 7 met the criteria for involuntary psychiatric admission because she was unable to maintain and function in a less restrictive environment.

4. At 11:30 AM. the the crisis worker documented an updated assessment of Patient 7.

The crisis worker documented that she had obtained collateral information from a psychiatric evaluation previously done at a local hospital. She also contacted the homeless shelter and received further information about patient 7. The staff person at the homeless shelter stated that she could come back there. Based on that information the crisis worker concluded that the patient was at her baseline condition. The crisis worker documented that she spoke with patient 7 again. Patient 7 informed the crisis worker that she could not stay at the homeless shelter. The crisis worker documented that it was her opinion that although patient 7 was severely mentally ill she was able to function and maintain in a less restrictive environment. Patient 7 did not meet the criteria for involuntary admission. The crisis worker indicated that the patient's risk of self harm was minimal and she would return to the homeless shelter.

The patient was discharged from the ED at 2:42 PM.

MEDICAL RECORD REVIEW FOR THE SECOND EMERGENCY DEPARTMENT VISIT

Patient 7 returned to the ED at 2:54 PM, twelve minutes after leaving the ED. Patient 7 was accompanied by the police who again pink slipped the patient to the hospital. The pink slip documented that patient 7 was: "a danger to herself and others. Pt is acutely psychotic. Pt. in need of inpt (inpatient) tx (treatment) and evaluation".

1. Review of the triage nurse's documentation revealed the following information:

The nurse documented that patient 7 was brought to triage by police officers. The officers reported that patient 7 was found standing in the middle of the road between the lanes of traffic. The nurse documented that patient 7 appeared anxious and was unaware of her situation.

2. Review of the nurse's progress notes revealed the following:

The nurse documented that from the time patient 7 returned to the ED she was attempting to go out the door. The nurse documented that patient 7 was informed that she was found in the middle of the street and the police brought her back to the hospital. The nurse documented that when she asked patient 7 why she didn't go to the shelter she stated it was because she was tired of it. Patient 7 stated she was in the middle of the road because she was tired of everything.

3. Review of the physician's documentation revealed the following information: The patient arrived at the ED accompanied by the police and was agitated, delusional and paranoid. The physician documented that patient 7 was "found wandering" and displayed angry, paranoid and unusual behavior. The physician documented that patient 7 had been discharged to the homeless shelter but was returned to the ED by the police who found her wandering. The physician documented that patient 7 returned to the ED due to an acute exacerbation of chronic psychosis.

4. The medical record included documentation of a crisis evaluation on 9/29/11 at 4:00 PM. The crisis worker who did this evaluation was not the same individual who had previously evaluated patient 7. Review of the crisis worker's assessment revealed the following information:

The crisis worker documented that patient 7 had been seen in the ED that morning after spending the night in jail on a trespassing charge. Patient 7 had been discharged from the ED to the homeless shelter and was later found wandering in the middle of a busy street near the hospital and was returned to the hospital in police custody. The crisis worker documented that she was unable to fully assess the patient due to her inability to answer questions. The mental status examination documented patient 7 as disheveled, guarded, hostile, paranoid, angry and floridly psychotic. The crisis worker documented that patient 7 was unable to care for herself in her current mental condition and required inpatient treatment.

The medical record included an emergency application for involuntary commitment. The form was signed by the crisis worker and stated that patient 7 was confused and disoriented, arrested for trespassing, and was found wandering in the middle of a busy street. Patient 7 was described as being unable to provide information about herself and was unable to maintain her safety and care for herself in her current mental condition and required inpatient treatment.

INTERVIEWS

1. A telephone interview was conducted at 12:30 PM. on 12/7/11, with the crisis worker who evaluated patient 7 during her first ED admission. The interview revealed the following information:

The crisis worker stated that the patient was pink slipped from the jail. When she first evaluated patient 7 she felt that patient 7 was delusional and unable to care for herself. The crisis worker stated that she called the homeless shelter where patient 7 had been staying. The shelter employee informed the crisis worker that patient 7 had been there the night before and became angry. The police were called and patient 7 was arrested for trespassing. The shelter employee stated that the shelter was willing to accept patient 7 back.

The crisis worker stated that she called a local hospital where patient 7 had recently been evaluated for similar symptoms. The crisis worker stated that based on her evaluation at that time and the information obtained from the homeless shelter it was determined that patient 7 did not require inpatient treatment. She concluded that patient 7 was at her baseline functioning and thus stable for discharge.

The crisis worked stated that patient 7 presented as street wise and knew she was to return to the homeless shelter. The crisis worker stated that patient 7 had her own bus pass and had a card in her wallet with the shelter's address and telephone number on it.

2. A telephone interview was conducted with the ED physician who evaluated patient 7 in the ED. The physician stated that patient 7 was evaluated by the crisis worker who decided the patient needed to be admitted as an inpatient to psychiatric hospital. The physician stated that the decision to admit a patient involuntarily is made jointly by the crisis worker and the physician. The physician stated that she was informed by the crisis worker that patient 7 needed inpatient treatment and the crisis worker was going to find a bed for patient 7. The crisis worker returned and informed the physician that after making calls to a local hospital where patient 7 had recently been evaluated and the homeless shelter where patient 7 had been staying that patient 7 appeared to be at her baseline functioning. The physician stated that patient 7 had been calm, cooperative and had not given the ED any problems and seemed to be functioning at her baseline. The physician stated that patient 7 did not exhibit any suicidal or homicidal ideation and displayed no evidence of hallucinations or delusions. Patient 7 had a place to stay at the homeless shelter where she agreed to go. The physician stated that patient 7 was given a bus token and knew how to get to the shelter. The physician stated that there was no grounds for patient 7 to be involuntarily committed because she was not suicidal or homicidal. The physician stated there was no way to predict that patient 7 would return to the ED.

The hospital failed to provide needed treatment for patient 7's psychiatric condition. The patient was discharged into the community rather than kept in the ED for ongoing monitoring to ensure her safety, until an appropriate transfer to a hospital with facilities to treat patient 7 could be arranged. Patient 7 was discharged from the ED after being instructed to take the bus to the homeless shelter. The patient was returned to the ED in the custody of the police after being found wandering in traffic.

REVIEW OF THE RECEIVING HOSPITAL MEDICAL RECORD

Review of the medical record from the psychiatric hospital where Patient 7 was transferred revealed the following information:

Patient 7 was emergently committed to the psychiatric hospital. Review of the Certificate for Emergency Commitment, dated 9/29/11, revealed that the reason for commitment was: "Pt. is a danger to herself and others. Pt. is acutely psychotic. Pt. is in need of inpt. Tx (treatment) and Eval.

Review of the physician's discharge summary from the psychiatric hospital revealed the following:

Patient 7 was a homeless woman with a history of psychosis who was admitted to the hospital as a transfer from the St. Marks ED on 9/30/11. The reason for admission was documented as decompensating symptoms of psychosis with inability to care for self in a less structured environment and not functioning.

The physician described the history of patient 7's present illness. Patient 7 was taken to the ED at St. Marks because she was found wandering in traffic and was delusional and paranoid. While in the hospital patient 7 was making bizarre statements and did not make sense. She had difficulty answering questions. "She did not make sense to the staff in the Emergency Department as well". Patient 7 had reportedly been living at a homeless shelter and had been agitated and uncooperative. The physician documented that on September 25 patient 7 went to a different ED and complained that she had nowhere to live. She had been hospitalized a few days prior to that but informed the physician that she had refused to take medication there. The patient, according to a psychiatric evaluation conducted on September 25, was paranoid. Patient 7 had been living in homeless shelters and short stay hotels. Because patient 7 was unable to care for herself and was markedly psychotic she was admitted for further evaluation and treatment.

The physician documented that the morning after admission the patient became agitated to the point of requiring chemical sedation. Patient 7's behavior was unpredictable, disorganized and she had attempted to assault staff. Patient 7 required restraints and seclusion due to a safety concern to herself and other patients. The physician documented that the agitated behavior continued for the first several days of hospitalization and the patient required continuous 1:1 supervision.

After being in the psychiatric hospital for 34 days the physician documented that patient 7 was unable to stabilize sufficiently from a psychiatric standpoint and required ongoing evaluation and care. Patient 7 was discharged from the psychiatric hospital to a state facility.

Review of the patient's medical record from the receiving hospital revealed that even after 34 days of treatment in a structured, psychiatric setting the patient was not stable enough to discharge to the community and required commitment for long term treatment.