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Based on interview and review of hospital documents, the hospital failed to adequately assess the mental health condition for 1 of 5 patient records reviewed (Patient #1) with an emergency mental health condition.

Failure to adequately assess patients with mental health conditions puts the patient and/or the public at risk for harm.

Findings included:

1. Record review of the hospital policy titled "EMTALA" (Emergency Medical Treatment andLabor Act), revised 05/01/18 showed that all patients are to be evaluated, stabilized, and sent for further treatment as indicated for the patient's condition.

2. Review of the patient's medical record showed the patient was brought by local law enforcement to the hospital on 01/19/19 in a confused mental state with thoughts of harming others. The patient was examined by the physician and the mental health professional. The mental health professional report indicated the patient was "gravely disabled" and not able to care for themself. The patient was unable to plan for safety and showed no insight into their symptoms and did not have family that could manage the patient's symptoms. The report stated the patient met the criteria for detention. It was recommended that the patient remain in the emergency room until an appropriate facilty could be located to provide care for the patient.

3. On 04/02/19 at 1:38 PM, Patient #1, was interviewed. Patient #1 did not remember coming to the local hospital emergency room. Patient #1's family member was interviewed with Patient #1's permission. The family member was present when the patient was in the emergency room.

The family member stated the patient was discharged from the emergency room despite the family member being unable to manage the patient's violent outbursts.The patient was set up with a mobile mental health outreach that was going to come to the patient's home in a few days. The patient had another violent outburst before the first scheduled mobile outreach appointment. The patient was taken to another hospital where they received treatment and was connected with a psychiatric primary care provider.

4. On 04/02/19 at 3:30 PM, Staff #1, a physician, was interviewed. Staff #1 stated on the day they took care of the patient the mental health professional stated verbally the patient did not need to be detained. The staff member did not have the completed mental health assessment until 2 days later when the patient had already been discharged 2 days earlier from the emergency room.

5. On 04/02/19 at 4:00 PM, Staff #2, a compliance officer, and Staff #3, a licensed nurse, were interviewed. They both stated that staff are to make sure they have a written report from the mental health professional before patient's with mental health conditions are discharged from the emergency department to ensure patients are discharged to a safe setting.

Based on interview and review of hospital documents the hospital failed to provide for the transfer of a patient for 1 of 5 patient records reviewed (Patient #1) with an emergency mental health condition.

Failure to transfer patients with mental health conditions to an appropriate care setting puts the patient and/or the public at risk for harm.

Findings included:

1. Record review of the hopsital policy titled "EMTALA" (Emergency Medical Treatment andLabor Act), revised 05/01/18, showed that all patients are to be evaluated, stabilized, and sent for further treatment as indicated for the patient's condition.

2. Review of the patient's #1's medical record showed the patient was brought by local law enforcement to the hospital on 01/19/19 in a confused mental state with thoughts of harming others. The patient was examined by the physician (Staff #1) and the county mental health professional (Staff #5) . The mental health professional report indicated the patient was "gravely disabled" and not able to care for themself. The patient was unable to plan for safety and showed no insight into their symptoms. Patient #1's family could not manage the patient's symptoms at home. The documentation in the medical record showed that the mental health professional recommended that the patient remain in the emergency room until an appropriate facilty could be located to provide care for the patient.

3. On 04/02/19 at 1:38 PM, Patient #1, was interviewed. Patient #1 did not remember coming to the local hospital emergency room. Patient #1's family member was interviewed with Patient #1's permission. The family member was present when the patient was in the emergency room.

The family member stated the patient was discharged from the emergency room despite the family member being unable to manage the patient's violent outbursts.The patient was set up with a mobile mental health outreach that was going to come to the patient's home in a few days. The patient had another violent outburst before the mobile outreach was even started. The patient was taken to another hospital where they received treatment and was connected with a psychiatric primary care provider.

4. On 04/02/19 at 3:30 PM, a physician (Staff #1) was interviewed by the investigator. Staff #1 stated that on the day the patient was in the emergency room the county mental health professional who examined the patient, verbally stated that the patient did not need to be detained. Staff #1 did not have the completed mental health assessment until 2 days later when the patient had already been discharged from emergency department.

5. On 04/02/19 at 4:00 PM, the compliance officer (Staff #2), and a licensed nurse (Staff #3) were interviewed. They both stated that staff are to make sure they have a written report from the mental health professional before patient's with mental health conditions are discharged from the emergency department to ensure patients are discharged to a safe setting.