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Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) and stabilization for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements," revised 07/01/24, showed the hospital's ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists. If an EMC is determined to exist, the hospital must provide either further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or provide an appropriate transfer to another medical facility. An EMC exists if there is a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances such that the absence of immediate medical attention could reasonably be expected to result in acute psychiatric symptoms that are manifested and if the individual is determined to be a danger to self or to others. To stabilize means to provide medical treatment of the condition to assure within reasonable medical probability, that no deterioration of the condition is likely to result from or occur if discharged or transferred.

Review of the hospital's policy titled, "Behavioral Health (BH) Admission and Exclusionary Criteria," reviewed on 03/2021, showed that all patients admitted to the BH Unit must meet at least one of the admission criteria that included a patient having physically aggressive threats or actions that pose an imminent risk of harm to self or others due to a treatable primary psychiatric condition and patient needs exceed an outpatient level of care for a treatable psychiatric condition.

Review of the hospital's policy "Organization Wide Patient Assessment," reviewed on 04/2024, showed that each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient's condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary.
Please refer to 2407 for further details.

Based on interview, record review, and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24, when they were discharged with an unstable medical condition.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements," revised 07/01/24, showed the hospital's ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists.

Review of the hospital's policy "Organization Wide Patient Assessment," reviewed on 04/2024, showed each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient's condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary.

Review of Patient #1's medical record dated 04/18/23 through 04/19/23, showed the following:
- She presented to the ED on 04/18/23 at 2:41 PM, via police, for an angry outburst at her day program and threatened to harm herself.
- She received a mental health evaluation and did not meet criteria for an inpatient admission to the Behavioral Health Unit (BHU). The physician documented that Patient #1's actions were attention seeking and behavioral. The provider did not feel that medication changes would benefit the patient. Physicians did not feel that Patient #1 was an imminent threat to herself or others and was to follow up with her outpatient providers. Her host family was not comfortable with her returning home that night, so the hospital agreed to let the patient stay until the morning of 04/19/23.
- On 04/19/23 at 12:15 AM, Patient #1 became escalated, grabbed a tongue depressor through the nursing station window and broke it in half, threatened staff, banged on the windows, and tried to get through the locked doors. She required sedation medications intramuscularly (IM, in the muscle). There was no documentation of a mental health evaluation following the incident.
- Fifteen-minute rounding sheets showed Patient #1 remained in a hallway bed throughout her ED visit and was not admitted to the hospital.
- Patient #1 was discharged with her host mother on 04/19/23 at 5:30 PM.
- Patient #1 did not receive a second mental health assessment after her outburst in the ED requiring sedation medication; a change of condition and as part of her MSE to determine the presence of an EMC.

Review of a document from Facility B, Police Department (PD), showed four officers responded to a 911 call on 04/18/23 at 1:46 PM for a possible armed assault. Patient #1 had a knife. She had been at the day center and had been cutting herself with a plastic fork. Her guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) did not feel safe transporting her to the ED and requested help from the PD. She was de-escalated and transported to Research Medical Hospital ED for an evaluation.

Review of an email dated 07/10/24 at 1:31 PM titled, "Notes on [Patient #1]," showed the following:
- On 04/18/23 at 7:24 PM, a Behavioral Health Assessment (BHA) was completed and discharge was recommended. The host mother did not feel comfortable returning home with the patient without her husband present and Staff Y, ED Physician, agreed to keep Patient #1 overnight.
- On 04/19/23 at 12:38 AM, Staff Y called and reported to the crisis stabilization unit that Patient #1 was very aggressive and required IM sedation. Staff Y reported that Patient #1's aggression and agitation was not normally at this level when the patient presented to the ED. The patient was making gestures to staff swiping her thumb across her throat.

During an interview on 07/09/24 at 4:00 PM, Staff CC, ED Physician, stated that Patient #1 was attention seeking and did not have a status change. He felt that it was ok to proceed with the discharge plan.

Although requested, interviews were not provided for Staff X, CM; Staff Y, ED Physician; Staff Z, ED Physician; Staff AA, RN; Staff BB, RN; and Staff LL, Patient Care Technician, PCT.

At the time of the patient's initial presentation, she had an appropriate MSE. However, the patient's behavior escalated and Patient #1 required sedative medications. She did not receive a new MSE following a change in condition on 04/19/23 at 12:15 AM in the ED. Patient #1 was discharged.

Based on interview, record review, and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24, when they were discharged with an unstable medical condition.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements," revised 07/01/24, showed the hospital's ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists. If an EMC is determined to exist, the hospital must provide either further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or provide an appropriate transfer to another medical facility. An EMC exists if there is a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances such that the absence of immediate medical attention could reasonably be expected to result in acute psychiatric symptoms that are manifested and if the individual is determined to be a danger to self or to others. To stabilize means to provide medical treatment of the condition to assure within reasonable medical probability, that no deterioration of the condition is likely to result from or occur if discharged or transferred.

Review of the hospital's policy titled, "Behavioral Health (BH) Admission and Exclusionary Criteria," reviewed on 03/2021, showed that all patients admitted to the BH Unit must meet at least one of the admission criteria that included a patient having physically aggressive threats or actions that pose an imminent risk of harm to self or others due to a treatable primary psychiatric condition and patient needs exceed an outpatient level of care for a treatable psychiatric condition.

Review of the hospital's policy "Organization Wide Patient Assessment," reviewed on 04/2024, showed that each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient's condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary.

Review of Patient #1's medical record dated 04/18/23 through 04/19/23, showed the following:
- She presented to the ED on 04/18/23 at 2:41 PM, via police, for an angry outburst at her day program and threatened to harm herself.
- She received a mental health evaluation and did not meet criteria for an inpatient admission to the Behavioral Health Unit (BHU). The physician documented that Patient #1's actions were attention seeking and behavioral. The provider did not feel that medication changes would benefit the patient. Physicians did not feel that Patient #1 was an imminent threat to herself or others and was to follow up with her outpatient providers. Her host family was not comfortable with her returning home that night, so the hospital agreed to let the patient stay until the morning of 04/19/23.
- On 04/19/23 at 12:15 AM, Patient #1 became escalated, grabbed a tongue depressor through the nursing station window and broke it in half, threatened staff, banged on the windows and tried to get through the locked doors. She required sedation medications intramuscularly (IM, in the muscle). There was no documentation of a mental health evaluation following the incident.
- Fifteen minute rounding sheets showed Patient #1 remained in a hallway bed throughout her ED visit and was not admitted to the hospital.
- Patient #1 was discharged with her host mother on 04/19/23 at 5:30 PM.

Review of a document from Facility B, Police Department (PD), showed four officers responded to a 911 call on 04/18/23 at 1:46 PM for a possible armed assault. Patient #1 had a knife. She had been at the day center and had been cutting herself with a plastic fork. Her guardian did not feel safe transporting her to the ED and requested help from the PD. She was calmed down and was transported to Research Medical Hospital ED for an evaluation.

Early in the patient's ED visit it was determined that she did not meet criteria for the BHU because she had just been discharged from there. It was noted in the ED record that she "exhibited attention seeking behaviors." Her foster mother did not feel safe having her return home. The patient had an outburst in the ED that required sedation with haloperidol and midazolam because she could not be verbally de-escalated. Despite the patient's aggressive behavior at the daycare and again in the ED, she was not stabilized prior to discharge.

Review of Patient #1's medical record dated 04/19/23 through 04/23/23, showed the following:
- Patient #1 presented to the ED on 04/19/23 at 9:08 PM, via police, for running away toward traffic from her group home manager. The police were called to get the patient back to the ED.
- Physician documentation showed Patient #1 paced around the ED, slammed a book shut and an affidavit (a written statement confirmed by oath, for use as evidence in court) was completed.
- On 04/20/23 at 07:29 AM, a mental health assessment was completed by Staff V, Social Worker (SW) and showed Staff CC, ED Physician, and Staff Y, ED Physician, both requested a recommendation for placement into a BHU as there was a concern for Patient #1's safety. Staff V recommended placement into a BHU.
- On 04/21/23 at 5:54 AM, physician documentation showed Patient #1 continued to meet criteria for placement on the BHU, but there continued to be no available beds.
- On 04/21/23 at 6:21 AM, physician documentation showed a mental health assessment was completed and the patient met criteria for placement in the BHU, due to repeated agitation and the host mother felt the patient was unsafe to return home. However, there were no available beds, so Patient #1 remained in the ED in a hallway bed in the psychiatric pod waiting for placement on the BHU.
- On 04/21/23 at 12:58 PM, Staff EE, Psychiatrist (physician who specializes in mental health disorders), documented a clinical note following a conversation with Staff Y, which showed Patient #1 did not appear to be a candidate for inpatient psychiatric treatment. He adjusted her medications and recommended outpatient treatment.
- On 04/22/23 at 6:06 PM, physician documentation showed a urine test was completed, Patient #1 had a urinary tract infection and antibiotics were started.
- On 04/23/23 at 7:54 AM, nursing documentation showed Patient #1 walked to the pod door with a blanket wrapped around her and over her head. Staff asked the patient if she needed to use the restroom or assistance, Patient #1 turned and walked toward the staff and stated she needed food because she was six months pregnant and she needed to leave. The patient got into the staff member's personal space and refused to back away. Patient #1 grabbed toward the staff member's groin area and continued to advance, yelling "stop raping her", then struck the staff member on the arms and upper body. Patient #1 was directed back to her bed and security was called for assistance. There was no sedation or physical restraints used to prevent the patient from harming others.
- On 04/23/23 at 7:57 AM, physician documentation showed a repeat mental health evaluation was completed and discharge was recommended at that time. Staff were reaching out to the guardian to inform her of the discharge from the ED.
- On 04/23/23 at 1:41 PM, nursing documentation showed Patient #1 hit, spit and smeared it on the window, and attempted to break a badge reader.
- On 04/23/23 at 2:26 PM, nursing documentation showed Patient #1 ripped skin off her right second finger and smeared blood on the window and door. There was no sedation or physical restraints used to prevent the patient from harming herself.
- On 04/23/23 at 3:11 PM, nursing documentation showed Patient #1 pressed the lockdown and emergency buttons, paced the hall, yelled and banged on the windows and tried to open doors. She stood on her cot and attempted to pull down the exit sign and attempted to pull equipment off the walls. Patient #1 was redirected back to her bed multiple times and security and off duty police were called. The guardian was called to pick up the patient.
- On 04/23/23 at 3:24 PM, case management (CM) notes showed nursing staff informed her that the police would be called on Patient #1's guardian if they did not pick up the patient in the next one to two hours. They would have the patient arrested due to aggression against ED staff and destroying property. The guardian was called and she refused to give consent for the patient to be discharged due to no one being at home; but reported if the ED staff wanted to call the police, she understood. The host mother spoke with the guardian and reported that she did not feel safe having Patient #1 in her home due to her behavior in the ED.
- On 04/23/23 at 3:28 PM, physician documentation showed Patient #1 began having anxiety about going back to her group home and was given medications for anxiety.
- Patient #1 was discharged from the ED on 04/23/23 at 9:34 PM.

Review of Patient #1's medical record from Hospital B, dated 04/24/23, showed Patient #1 presented to the ED, via police with agitation and combativeness. Patient #1 ran from her home and police found her running on a busy interstate ramp, she was restrained and taken to Hospital B. She was placed in four-point restraints at Hospital B and required sedative medications. She had a mental health assessment and on 04/25/23 was admitted to the BHU at Hospital C for being a danger to herself and others.

Review of Patient #1's medical record from Hospital C, dated 04/25/23, showed Patient #1 was admitted 04/25/23 through 05/04/23 as a voluntary admission for work-up and management of erratic behavior.

Review of an email dated 07/10/24 at 1:31 PM titled, "Notes on [Patient #1]," showed the following:
- On 04/18/23 at 7:24 PM, a Behavioral Health Assessment (BHA) was completed and discharge was recommended. The host mother did not feel comfortable returning home without her husband present and Staff Y, ED Physician, agreed to keep Patient #1 overnight.
- On 04/19/23 at 12:38 AM, Staff Y called and reported to the crisis stabilization unit that Patient #1 was very aggressive and required IM sedation. Staff Y reported that Patient #1's aggression and agitation was not normally at this level when the patient presented to the ED. The patient was making gestures to staff swiping her neck across her throat.
- On 04/19/23 at 8:06 PM, it was noted that the ED attempted to discharge Patient #1. Patient #1 refused to get in the car and ran to a parking garage. A call was made to the police, she was apprehended and brought back to the ED. Patient #1 was sedated with Versed (medication used to help patients feel relaxed or sleep) 5 mg and Haldol (medication used to treat mental disorders by decreasing excitement of the brain) 5mg due to aggression. Staff Y wanted the patient admitted but did not want another BHA completed.
- On 04/20/23 at 06:33 AM, Staff CC, ED Physician, called and stated that Patient #1 needed a BHA. Staff CC was informed that Staff Y had not wanted a new BHA done because the plan was to have her admitted if she returned. Staff CC stated he wanted the patient assessed because it would be impossible to place the patient with a BHA that stated discharge.
- Twelve BHU's were contacted for placement and a blast email (act of sending a single email message to a large email list simultaneously) was sent requesting placement.
- On 4/21/23 at 11:25 AM, Staff EE, Psychiatrist, was not willing to accept Patient #1 to the BHU she had been recently discharged from and stated that there was no psychiatric benefit for her being admitted. Staff Y requested to speak with Staff EE to discuss Patient #1.
- On 04/21/23 at 1:43 PM, the crisis stabilization unit called Staff Y and stated that Staff EE documented he would not be accepting Patient #1 back in the BHU. Staff Y stated they were not comfortable discharging the patient. Staff Y requested that the transfer center continue placement efforts. Staff Y stated that if Patient #1 did well with medication and does not continue to have behaviors that required prn medications, they would consider discharge.
- On 04/22/23 at 6:13 PM, Staff Z, ED Physician, ordered a psychiatric evaluation for discharge.
- On 04/22/23 at 8:10 PM, Patient #1's case was closed as the psychiatric evaluation recommended discharge.

Review of an undated document titled, "Behavioral Health Assessment," showed on 04/20/23 at 7:29 AM, Staff V, SW, documented that self-harm, aggressive behavior, and eloping from the ED was the behavior resulting in a 911 call for Patient #1. Documentation showed Staff CC, ED Physician, and Staff Y, ED Physician, were both requesting admission of Patient #1 due to a concern for patient safety as a result of her aggressive behavior, self-harm and her recent elopement from the ED. She denied suicidal ideation (SI, thoughts of causing one's own death)/ homicidal ideation (HI, thoughts or attempts to cause another's death) thoughts. Staff V did discuss the assessment with the guardian and documented the guardian reported they did not feel safe for Patient #1 to return to her home. The guardian filled out an affidavit attesting to her concerns of patient safety. Psychiatric admission would be pursued per request from guardian, Staff CC and Staff Y. The recommendation of patient disposition was to admit the patient and was discussed with Staff CC.

Review of the document titled, "Affidavit in support of Application for detention, evaluation and treatment rehabilitation," dated 04/24/23 showed Patient #1 was trying to walk out of the door at home and became aggressive. She took off and headed towards the highway. Patient #1 had been discharged from Research Medical Center (RMC). She had put holes in the walls and was fighting with staff and was told she could not return to RMC. The police had been called and during the attempt to apprehend Patient #1, she spit on the officers and attempted to break the windows on the police car.

Review of the document titled, "Affidavit in support of Application for detention, evaluation and treatment rehabilitation, dated 04/24/23 showed the police had been dispatched and found Patient #1 on a busy intersection. She was handcuffed and put in the patrol car. Patient #1 attempted to kick out the rear window, yelled racial slurs and spit. She was transported to Hospital B per request of guardian.

During an interview on 07/09/24 at 4:00 PM, Staff CC, ED Physician, stated that Patient #1 was attention seeking and her behavior was congruent behavior with previous admissions. She remained stable at her baseline behavior and was cleared by a psychiatrist for discharge. Staff CC stated that he felt that discharge was appropriate.

During an interview on 07/10/24 at 11:00 AM, Staff V, SW, stated that she worked as a counselor doing crisis stabilization. She did mental health assessments for patients who presented to the ED for a mental health evaluation. She did perform a mental health assessment on 04/20/23 for Patient #1. She recommended admission to a BHU. Staff V stated that Patient #1 was a danger to self and to others based on her behaviors. The intake unit would then try to find placement for patients requiring in-patient care. If there was a delay in finding inpatient care, the ED would typically order a psychiatrist to assess the patient. The psychiatrist could then usually clear the patient for discharge. Staff V stated that Patient #1 "was definitely a threat to self and others and needed to be placed in an inpatient BHU."

During an interview on 07/16/24 at 11:21 AM, Staff W, RN, stated that he was involved in an incident with Patient #1 on 04/22/23 at 6:55 AM when she put a blanket over her head and told Staff W that she was six months pregnant and needed some food so she could leave. She was asked to back away from Staff W's personal space and she refused. Patient #1 got aggressive, swinging hard at Staff W and attempting to make contact with the groin area. A panic button was pushed and Patient #1 was held until security arrived. Staff W stated that when a behavioral health patient had an extended stay in the ED, they should show a major improvement in order to be discharged. Staff W stated that at times, if they were unable to find placement for a BHU, they would do a psychiatry telehealth visit to get an order for discharge. "She was clearly mentally disturbed and not mentally stable."

During a phone interview on 07/17/24 at 8:10 AM, Staff GG, RN, stated that it was typical if there was a patient awaiting placement into an inpatient BHU and they were having trouble finding placement, the physicians made a referral for psychiatry telehealth for an assessment to see if they could discharge the patient. The telehealth psychiatrist reviewed the history and talked to the patient. If a patient answers "no" to SI/HI questions, they would often make a medication adjustment and discharge the patient for outpatient care.

During a phone interview on 07/17/24 at 3:19 PM, Staff FF, Psychiatrist, stated that he does psychiatric telehealth assessments. He stated that Staff Z, ED Physician, ordered a mental health assessment for Patient #1. Staff FF stated that Patient #1 had been in the ED several days and was awaiting placement for BHU inpatient care, but they were having problems finding placement. The ED would typically order a psychiatric mental health assessment to see if they could get an order for a therapeutic discharge if they were unable to find placement. He stated that he did an assessment on Patient #1 and that she denied having any SI/HI thoughts and was having behavioral issues. He increased her medications and ordered a therapeutic discharge. He stated that he did not speak with the ED physician but did review her medical record prior to his assessment.

During a phone interview on 07/18/24 at 2:50 PM, Staff EE, Psychiatrist, stated that he received a phone call from Staff Z, ED Physician asking a favor. He stated that Patient #1 had been in the ED and that Staff Z would like him to write a note and discharge the patient. Staff EE stated that he never saw the patient in the ED and typically does not see patients in the ED. He did write the note based on her recent inpatient visit with him on 04/17/23. She had been discharged from the BHU of an acute hospital and he felt that it wasn't benefiting her. Staff EE stated that her behaviors were getting worse but that it could have been because of the ED setting, but he did not see or talk to the patient at that time.

For an acute mental health crisis, the patient needed inpatient psychiatric treatment to protect her from harming herself or others. When the patient's behavior in the ED escalated to the point that she was harming herself and others, physical restraints and/or sedation was needed and not provided.

Although requested, interviews were not provided for Staff X, CM; Staff Y, ED Physician; Staff Z, ED Physician; Staff AA, RN; Staff BB, RN; Staff JJ, RN; and Staff LL, Patient Care Technician (PCT).