HospitalInspections.org

Based on interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.24(a)(1)(i): The facility failed to provide appropriate medical screening examinations to include documentation of continued monitoring for 3 (#s 4, 14, and 19) of 20 sampled patients who presented to the ED (emergency department) for emergency care.

Findings Include:

Review of a facility policy titled, EMTALA- Emergency Medical Treatment and Active Labor Act, not dated, showed:
" ...An appropriate medical screening examination should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of on-call physicians and ancillary tests or services routinely available to the Hospital if needed to determine whether an emergency medical condition exists. The chart should document continued monitoring until the patient is stabilized or transferred ..."

Review of a facility policy titled, Suicide Risk Screening and Suicide Precautions for Patients, not dated, showed:
"Purpose: The purpose of this policy is to outline practices for the identification, assessment, and prevention of self-harm or attempted suicide by at risk patients during their emergency room visit or hospitalization ...
Suicide Risk Screening using the Columbia-Suicide Severity Rating Scale (C-SSRS):
All patients age 12 and older presenting for care in the Emergency Room...will have an initial suicide risk assessment completed upon admission using the Columbia-Suicide Severity Rating Scale (C-SSRS)....
Emergency Department (ED): Any patient presenting to the ED with a chief complaint of suicidal/homicidal ideation with intent or intent with a plan with the last month OR suicidal/self-harm behavior should be automatically placed on 1:1 observation until further evaluation can be completed. The ED nurse will perform the C-SSRS ... during triage to determine if a patient is at risk for suicide and if so, what level of risk they are.
High Risk (8+) ... 2. Order and initiate 1:1 observation and monitor for elopement risk. Document observations every 15 minutes. Staff must maintain direct observation at all times..."
Review of a facility policy titled, Signing Out Against Medical Advice- AMA, not dated, showed:
" ...2. The release of responsibility form will be signed by the patient before leaving ... 5. Staff will document medical record with details of the situation, regardless if the patient signed the AMA form or not."

1) Patient #4 presented to the ED on two occasions. On the first visit, patient #4 presented to the ED with complaints of suicidal ideation and alcohol intoxication. Patient #4 was not placed in a suicide safe place on arrival. He was voicing suicidal thoughts and was not provided with one-to-one observation with documented 15-minute safety monitoring. The mental health evaluation did not include assessment of when his last suicidal thoughts were, or his previous attempts at self-harm. Minimal information was obtained about the patient's prior psychiatric, mental health, and medical history. Only one set of vital signs was obtained during the 9 hours and 15 minutes he was in the ED. Patient #4 was given both Haldol and Ativan (medications that can affect level of consciousness, blood pressure, and respiratory status), which required a repeat assessment of blood pressure after administration. Patient #4 was discharged from the ED. On the second visit, patient #4 presented to the ED with chest tightness, left arm pain, alcohol intoxication, syncope (medical terminology for passing out or losing consciousness), and suicidal ideation. Patient #4 was in the ED from 7:07 p.m. to 11:50 p.m. Vital signs were documented only one time while in the department. No laboratory tests or diagnostics were ordered to determine a cause for the patient's chest tightness and left arm pain. The patient reported suicidal ideation, and the medical record did not show he was placed on one-to-one observation. There was no documentation of 15-minute observations of patient #4 per hospital policy. (See C-2406)

2) Patient #14 presented to the ED with complaints of erratic behavior at the jail. It was reported the patient passed out twice. The EMR (electronic medical record) failed to show investigation into the cause of patient #14's syncope (loss of consciousness). Only one set of vital signs were documented for the patient during the 2 hours and 15 minutes he was in the ED. There was no evidence the patient had continuous cardiac monitoring, as would be appropriate for assessing the syncopal episodes. Vital signs were not repeated after the patient was administered intravenous Ativan, which had the potential to affect his level of consciousness, blood pressure, and respiratory status. Patient #14 stated he was suicidal while he was in the ED, yet no suicide assessment was documented, and no mental health evaluation was performed. (See C-2406)

3) Patient #19 presented to the ED five times over a period of three days for complaints of acute alcohol intoxication. During the first visit there was no blood pressure documented. Patient #19 received Ativan, Benadryl, and Haldol for behavioral control (all of which can affect level of consciousness, breathing, and blood pressure). The provider notes showed patient #19 left against medical advice. The blood pressure should have been taken and reassessed multiple times during this patients stay, and the patient's departure AMA does not excuse the lack of blood pressure assessment. On the second visit, patient #19 arrived via ambulance with a GCS (Glasgow Coma Score, indicates level of consciousness 3-15, 15 is normal and 3 would be comatose) of 10. The GCS was never reassessed and there was no repeat exam documented by the QMP to evaluate improved mentation. The likelihood of a head injury or intracranial bleed was not clearly ruled out. There was no screening for mental health concerns. Patient #19 had an elevated Lactic Acid level (elevation can be caused by seizures, liver disease, infection, intoxication, etc.) which was not investigated. The record indicated patient #19 left AMA, however, the EMR lacked a signed AMA form showing the patient was advised of the risks of leaving the facility AMA. On the third visit, patient #19 returned to the ED with concerns about alcohol withdrawal and anxiety/panic attacks. During his triage assessment he was found to be tachycardic (high heart rate), which can be a sign of alcohol withdrawal. No EKG was performed, and patient #19's heart rate was never reassessed. The QMP did not document assessment questions for alcohol withdrawal. Patient #19's lactic acid was elevated and not investigated. No mental health evaluation was completed. Patient #19 was discharged from the ED. During patient #19's fourth visit to the ED, the record showed patient #19 returned thirty minutes after being discharged from the previous visit with law enforcement stating he was worried about having seizures from alcohol withdrawal. The nurse told law enforcement patient #19 had just been discharged with a high blood alcohol so he was not at risk of withdrawal seizures. There was no documentation showing the nurse explained the risks of leaving without being seen by the provider. There was no MSE, no triage assessment, and no vital signs documented. Patient #19 left with law enforcement without being seen. On patient #19's fifth visit to the ED, he presented complaining of potential seizures and anxiety. Patient #19 was again tachycardic. The patient had an elevated lactic acid level that had not yet been fully explored on any prior visit and now had concerns for seizures (which can cause an elevated lactic acid), however, a lactic acid level was not repeated. In addition, other causes of lactic acidosis had still not been ruled out. The patient was not placed on a cardiac monitor for ongoing tachycardia. Given the concern for seizures, the patient was not placed on seizure precautions. Patient #19 was administered Ativan twice, and there was no documentation of vital signs being repeated. Patient #19 remained anxious and tachycardic from visit number three through visit number five. He was discharged to a law enforcement officer with instructions to be taken to the bus station. (See C-2406)

Based on interview, record review and policy review, the facility failed to provide appropriate medical screening examinations to include documentation of continued monitoring for 3 (#s 4, 14, and 19) of 20 sampled patients who presented to the ED for emergency care. Findings include:

1) Visit #1: Review of patient #4's EMS report dated, 8/20/24 at 12:54 a.m., showed, "Called out to the local gas station for a male patient that is extremely intoxicated and is suicidal. Upon arrival, officers are on scene with the patient. Patient has two small cuts on his left forearm, about 1 inch in length, deep enough to require medical attention. Patient admits to cutting himself with the intent to harm himself. The patient is compliant but very intoxicated, with an unsteady gait ..."

Review of patient #4's EMR (electronic medical record) showed patient #4 presented to the ED (emergency department) on 8/20/24 at 1:47 a.m. complaining of intoxication and intentionally cutting himself with a pocketknife.

Review of patient #4's triage note, dated 8/20/24 at 1:50 a.m., showed, "Patient was brought in by EMS (emergency medical services) and PD (police department) after he cut his arms with a pocketknife while drunk." The C-SSRS (Columbia Suicide Screening, assessment used to determine suicide risk) screening was not done due to the patient's intoxication even though he was noted to be alert and oriented to person, place, time, and situation and he had a GCS of 15 (Glascow Coma Scale- an assessment of eye, verbal, and motor responses to determine level of consciousness. The scale is from 3, unconscious to 15, alert and oriented). An ESI (Emergency Severity Index- a five-level triage algorithm with 1 being the most severe and 5 the least) level of 4 was assigned to patient #4.

Review of patient #4's ED Report, authored by the QMP (ED provider) dated 8/20/24 at 2:12 a.m., showed, "Alcohol, left forearm lacerations from self-harm/cutting, possible suicide ideation ...He did make some comments apparently to law enforcement about wanting to kill himself ... When I asked him if he was feeling suicidal, he stated he was 'undecided' at this time ... He gestures to the underside of his left wrist, where he has multiple scars from previous cutting episodes, stating, 'I know how to do it ...'" He stated he had been wandering because he was unable to get a hotel or a place to stay. There was no inquiry as to hallucinations, delusions, or homicidal ideation documented. There was no specific inquiry into prior suicide attempts other than the gesture to the scars on his wrist. There was no documentation indicating how long ago patient #4 last attempted to hurt himself. The ED report showed, "Laceration #1 is approximately 2 cm in length, subcutaneous depth, occasionally oozing blood, approximately 3 cm from the elbow. Laceration #2 is approximately 5 cm in length, subcutaneous depth, occasionally oozing blood, approximately midway between elbow and wrist." There were no other questions regarding his suicidal ideation or thought process documented. The QMP's note showed patient #4 was cooperative with the suture repair, he had a blood alcohol level of 310, he was given Ativan 2 mg tablet, Haldol 5 mg tablet, and Keflex.

Review of patient #4's Behavioral Health Note, dated 8/20/24 at 9:42 a.m., showed patient #4 had made comments to law enforcement about wanting to kill himself. He said he did not have a place to live, and his recent relationship had failed. Patient #4 said he wanted to be hospitalized. Patient #4 verbalized he had previous psychiatric hospitalizations and stated he had a history of depression and anxiety. Patient #4 endorsed chronic suicidal thoughts and self-harm thoughts and stated, "I always have them." The behavioral health note showed, "[Patient #4] is a chronic risk based on substance abuse, homelessness, unemployment, and lack of social support. Psychiatric hospitalization is unlikely to change his condition; he reports he does not take medication and self-medicates instead. It is felt that he is leveraging suicide as a threat to coerce hospital staff into providing housing in the hospital setting ... The risk of reinforcing parasuicidal behavior to coerce providers to hospitalize him is felt to be outweighed by the benefit of reinforcing the importance of outpatient follow-up, absence from drugs and alcohol, and follow-through with the alcohol treatment."

Patient #4 was discharged at 10:09 a.m. Patient #4 was given discharge instructions. No information on suicide ideation was given beyond a suicide hotline number. His ESI level was assigned a 4 at triage and should have been a 2 given his verbalization of suicidal ideation. The patient had demonstrated cutting behavior that had not been ruled out as a suicide attempt. The mental health provider listed several risk factors for suicide, including substance abuse, homelessness, unemployment, medication non-compliance, and lack of social support. However, the mental health provider then concluded, despite all these risk factors, the patient was not at risk for self-harm. The C-SSRS was never completed during the visit. The EMR included only one set of vital signs. However, the patient was given both Haldol and Ativan.

During an interview on 10/10/24 at 9:25 a.m., staff member J said patient #4 told her he was a cutter, and she did not feel he was "actually suicidal." She stated she sutured his lacerations, let him sleep off his alcohol intoxication and spoke with the mental health provider and the medical director. She said she discharged him in the morning, after he was sober.

During an interview on 10/9/24 at 8:06 a.m., staff member K said Ativan and Haldol were given to patient #4 prior to her coming on shift. She stated vital signs should be taken every hour while a patient was in the ED, but she could not find evidence of hourly vital signs in the EMR. Staff member K stated she did not perform a C-SSRS screening at any time while patient #4 was under her care.

Visit #2: Review of patient #4's second visit on 8/20/24 at 7:07 p.m., showed, patient #4 returned to the ED with a chief complaint of "suicide ideation, alcohol abuse."

Review of patient #4's triage note dated 8/20/24 at 7:19 p.m., showed, patient #4 was brought in by EMS for a syncopal episode, chest tightness and right shoulder pain. The C-SSRS screening for this second visit showed patient #4 was at high risk for suicide.

Review of patient #4's Nursing Notes dated, 8/20/24 at 7:19 p.m., showed, "When Pt arrived, he stated he had chest tightness and right shoulder pain. After pt was placed in a room pt stated that he wasn't ready to leave when he was discharged this morning and that he was suicidal, and he just wanted to kill himself. Pt showed staff his arms and stated look at this, I was trying to kill myself and if I don't stay here, I'm just going to go kill myself."

Review of patient #4's ED report dated 8/20/24 at 7:13 p.m. showed, "He is complaining of chest tightness and right shoulder pain ...He had told law enforcement that he wanted to kill himself. He states that he 'just wants to die.' He is also complaining of right-sided chest pain and right shoulder pain. He feels short of breath at times." There was only one set of vital signs obtained during the visit. The ED report showed, patient #4 had pain in the epigastric area of his abdomen, there was no other assessment for abdominal pain. Patient #4 stated he had shoulder pain, there was no assessment documented of his shoulder to evaluate for trauma, swelling, redness, or other concerns. The ED record lacked documentation by the QMP of whether the patient was suicidal, homicidal, or had impairment of thought process, including delusions or paranoia. An EKG was performed that was abnormal, but the record lacked follow up testing such as a troponin level to show if the abnormal EKG and chest pain were of concern. The record lacked documentation of suicide precautions and 1 to 1 monitoring.

During an interview on 10/11/24 at 10:15 a.m., staff member I said she was working on 8/20/24 at 7:07 p.m. when patient #4 presented for the second time to the ED with law enforcement. She stated she was aware patient #4 had a syncopal episode when he was at the jail, but she said the deputies told her they felt he was syncopal due to his intoxication. Staff member I said patient #4 complained of tightness in his chest. Staff member I stated, "I did not do any cardiac workup for him (patient #4) other than an EKG." Staff member I stated although there were some abnormalities on the EKG, she didn't feel the patient's presentation warranted a cardiac workup. Staff member I said she expected patients would have vital signs taken in triage and when discharged at the very minimum. She stated if a patient had other complaints, had abnormal vital signs, received medication, or were unstable, she would expect those vital signs to be more frequent.

2) A review of patient #14's EMR showed, patient #14 presented to the ED via EMS for erratic behavior at the jail after he was arrested by law enforcement.

Review of an EMS report for patient #14 dated 7/6/24 at 5:27 p.m. showed, "Corrections staff (at the jail) had patient laying on the floor in hand and feet cuffs with staff holding the patient down. The patient was very verbal with threats and concerns. Correction staff stated the patient was brought in with dilated pupils and started to get very aggressive. Also, they believed he is on some sort of drug. Correction staff stated he did pass out twice briefly, which they believed to be positional." EMS reported a GCS of 15. No vital signs were found on the EMS record.

Review of patient #14's triage note dated 7/6/24 at 5:35 p.m., showed, patient #14 "Arrived by EMS with law enforcement. The patient was having erratic behavior at the jail." No C-SSRS was done on the initial evaluation by nursing staff. The reason for it not being performed was listed as "intoxicated."

Review of the ED record dated 7/6/24 at 5:41 p.m. showed, patient #14 had been sober for several months but relapsed on this day because he had been fired from his job. Patient #14's psychiatric exam showed he was initially uncooperative but then settled down. There was no assessment of judgment or insight documented. There was no inquiry into suicidal or homicidal behavior or thought processes documented. There was no evaluation of hallucinations or delusions documented. Lab tests were taken, his blood alcohol was 328. The ED record showed he was cleared for discharge but shortly before discharge, he became belligerent. Patient #14 took the bed sheet and stuffed it in his mouth. The sheet was removed from his airway, and he was given Ativan 1 mg intravenously. He was then discharged into the care of the local police department to be taken back to jail. No documentation was found in the chart for assessment of suicide risk or repeat psychiatric assessment by the QMP. There were no questions regarding suicide ideation, homicidal ideation, delusions, or hallucinations documented. The EMR lacked assessment from behavioral health. The initial C-SSRS was not done due to intoxication, and the assessment was not completed prior to discharge. The QMP's history does not include information about the syncopal events before arrival, and no workup or assessment for potential syncope was found in the history, exam, or testing. There was no documentation of cardiac monitoring and there were no vital signs documented after medications were given. There was no documentation of suicide precautions or one to one observation.

Review of a Nursing note dated 7/6/24 at 7:13 p.m. showed: "The patient states, 'I'd rather die than go back to jail.' Officers restrained the patient to the bed rail with handcuffs. Ativan 1 mg IV push given. Multiple other police officers and a corrections officer also arrived at the patient's bedside."

Review of a Nursing note dated 7/6/24 at 7:34 p.m., showed: "Multiple law-enforcement officers remain at the bedside."

Patient #14 was discharged at 7:42 p.m. into police custody. Discharge instructions were given for acute alcohol intoxication and alcohol use disorder.

During an interview on 10/11/24 at 10:15 a.m., staff member I stated, "The police told me he was just holding his breath. I don't recall anything about having loss of consciousness at all. With his degree of intoxication, they can pass out and come back so I might not have done anything differently in my MSE anyway." Staff member I said she did not feel patient #14 needed a mental health evaluation. She stated she felt he was just saying he wanted to die because he did not want to go back to jail. Staff member I stated she would expect vital signs to be taken every 30 to 60 minutes for any patient in the ED. She stated she did not know only one set of vital signs were taken for patient #14.

During an interview on 10/10/24 at 10:02 a.m., staff member N stated a mental health evaluation should always be done when a patient states they are suicidal. Staff member N stated she administered Ativan to patient #14. She stated it would be appropriate nursing practice to take vital signs after administering medications. Staff member N stated she could not find any vital signs in patient #14's chart other than the triage vital signs. She stated vital signs should also be taken when a patient was discharged from the ED. Staff member N stated she could not find any discharge vital signs in the EMR for patient #14. Staff member N stated she was the nurse who discharged patient #14. She stated she did not know why she did not take vital signs after she administered the medication, or when the patient was discharged. Staff member N stated she did not do a C-SSRS screening after patient #14 told her he wanted to die. She said she informed the provider the patient had expressed he was suicidal, but did not initiate 15-minute documentation and did not initiate one-to-one observation.

During an interview on 10/1/24 at 11:43 a.m., staff member E stated the facility had an adult behavioral health unit and always had MHE (Mental Health Evaluation) available.

3) Patient #19 presented to the ED 5 times in three days seeking emergency medical care. Visits were as follows:

Visit #1: Review of patient #19's EMR dated 5/16/24 at 5:11 p.m., showed, patient #19 presented to the ED via EMS with complaints of alcohol intoxication.

Review of an EMS report for patient #19 dated 5/16/24 at 4:49 p.m., showed EMS was called to patient #19 for substance abuse and alcohol use/intoxication. The initial pulse per EMS was 109 bpm (normal is 60-100 bpm), SPO2 was 91% (normal >90%), and initial GCS was 13 (scale from 3 unconscious-15 alert and oriented). EMS reported they were unable to obtain the patient's blood pressure.

Review of patient #19's triage note dated 5/16/24 at 5:33 p.m., showed, no blood pressure was documented at triage and no blood pressure was documented anywhere in the EMR during the visit. At 5:30 p.m., the nursing staff noted the patient as lethargic and unable to express orientation. No C-SSRS was done as the patient had an altered mental status. The patient was assigned an ESI of 5, non-urgent, despite confusion and inability to obtain a full set vital signs.

Review of patient #19's ED report dated 5/16/24 at 5:11 p.m., reflected patient #19's chief complaint was "alcohol intoxication." The ED report showed, patient #19 was brought in by EMS for alcohol intoxication. His mental status was altered, and he had difficulty ambulating. The report showed, "The patient does know his name and the city he is living in, but he's not able to answer other questions. He has difficulty following instructions." The neurologic exam stated only "no focal deficit," No psychiatric evaluation was documented on the initial exam. There was no initial assessment of judgment or insight documented. The blood alcohol level was elevated at 337. Patient #19 was placed on 2 liters of oxygen using a nasal cannula however, there was no documentation to show why. The QMP's history and physical showed, "Medical decision-making: The patient's blood alcohol level was found to be elevated in the 330s. He was uncooperative, pulling out IVs and stumbling in the room. He was eventually given IV Ativan, Haldol, and Benadryl to prevent him from accidentally injuring himself. Shortly after midnight, he woke up." Patient #19 was discharged as "left against medical advice" at 12:15 a.m., on 5/17/24.

Review of a nursing reassessment dated 5/17/24 at 12:10 a.m. noted patient #19 was alert and oriented to person, place, time, and situation with a GCS of 15. A detailed neurologic exam was not documented, and a behavioral health assessment was not documented. On the initial presentation, the patient was not cooperative with the C-SSRS, however a C-SSRS was not documented during the visit at any time. Except for intermittent pulse oximetry (not hourly), repeat vital signs were not documented until the patient left AMA, and the final set of vital signs did not include a blood pressure.

Review of a nursing note dated 5/17/24 at 12:15 a.m., showed the patient signed out AMA.

Visit #2: Review of patient #19's EMR dated 5/17/24 at 1:19 p.m., showed, patient #19 presented to the emergency department via EMS for alcohol intoxication.

Review of an EMS report for patient #19 dated 5/17/24 at 12:44 p.m., reflected an initial GCS of 10. Pulse oximetry per EMS was 90% on room air. The initial heart rate was 127 bpm.

Review of the ED record dated 5/17/24 at 1:01 p.m., showed a chief complaint, "brought in by EMS for alcohol intoxication ... He was minimally responsive." The QMP's report showed patient #19 was covered in urine on arrival. Movements were noted to be "ungraceful, with swaying and staggering." A lactic acid (a blood test to indicate if cells have enough oxygen and the liver and kidneys are processing lactic acid normally) was done and was elevated at 4 (normal < 2) and alcohol level was 407 (this level would be considered 5 times the legal limit to operate a motor vehicle).

Review of a nursing note dated 5/17/24 at 2:17 p.m., showed: "Patient went wandering again, asked what he needed, and asked about snack/water - no response. Patient urinated on the floor."

Review of a nursing note dated 5/17/24 at 3:35 p.m., showed, "Patient up to pee, patient refused the urinal. Patient back in bed after but starting to use actual words instead of grunts as he said 'what?'."

Review of a nursing note dated 5/17/24 at 6:55 p.m., showed, "Laying in bed. Woke up to answer a few questions." No clear assessment of speech, orientation or judgment was documented.

Review of the QMP's repeat examination on the ED record showed, "At 7:45 in the evening, he got up, got dressed, and asked where the exit is. He then left the building." Patient #19's GCS was never reassessed and there was an incomplete neurological exam. No AMA form was found, and no discharge instructions were found in the EMR. The EMR lacked a repeat assessment from the QMP, suicide screening, one-to-one observation documentation despite there being a one-to-one observation order in the EMR and lacked documentation of being provided the risks of leaving AMA.

During an interview on 10/2/24 at 8:58 a.m., staff member D confirmed there was no AMA form in patient #19's EMR for 5/17/24.

During an interview on 10/9/24 at 10:00 a.m., staff member H said she knew patient #19 was wanting to leave the ED. She stated the nurses are usually responsible for having the AMA form signed. Staff member H stated she did not inform patient #19 of the risks of leaving AMA. Staff member H stated she remembered he came in several times. She said he was "really drunk" and left AMA each time. She said she did give him medications to help him sleep during one of his visits. Staff member H said nurses should always take vital signs before and after administering medication. She said patients should always have discharge vital signs documented.

Visit #3: Review of patient #19's EMR dated 5/18/24 at 3:37 a.m., showed, patient #19 presented to the ED for anxiety, intoxication, and concerns for alcohol withdrawal. Despite tachycardia with a heart rate of 124 bpm, the patient was triaged as an ESI level four (less urgent). No C-SSRS exam was documented.

Review of the ED record dated 5/18/24 at 3:37 a.m., patient #19's chief complaint showed: "Patient brought in by ambulance for the third time in under two days for either alcohol intoxication or stated withdrawals from it." Patient #19, who reported homelessness, stated he had been allowed to stay in someone's camper, and he began having anxiety attacks and tremors (a symptom associated with alcohol withdrawal) before 2 a.m. so he purchased a bottle of vodka and drank it because he was afraid of having a withdrawal seizure. He called for the ambulance not long after he finished drinking the vodka and was transported to the ED. In triage, the patient's heart rate was elevated at 124 bpm (normal HR 60-100 bpm), however, this was not reassessed, and no EKG was found in the medical record. Patient #19 stated he was anxious about having withdrawals and reported "getting shaky" (sign of withdrawal). The record lacked further assessment for signs of withdrawal, such as the potential for hallucinations. The patient initially wouldn't respond to questions during the psychiatric examination, however, when he did respond, there was no documented evaluation of the patient's behavioral health risks, no documented assessment of suicidal or homicidal ideation, and no assessment of judgement or insight. Labs were significant for an elevated alcohol level of 294, and the patient's lactic acid remained elevated at 3.4. There were no repeat vital signs during his stay in the ED, and patient #19 was discharged "walking" on 5/18/24, at 5:31 am.

Visit #4: Review of patient #19's EMR for 5/18/24 at 6:08 a.m., revealed, patient #19 presented to the ED with law enforcement. The patient requested to be admitted to the facility so he wouldn't have alcohol withdrawal complications. Patient #19 was not offered a MSE when he presented to the ED, and it was not determined if the patient had an EMC. No triage assessment or vital signs were taken during this presentation to the ED.

Review of patient #19's EMR nursing note, dated 05/18/24 at 6:02 a.m., showed, "The patient actually returned, this time with [local police department]. He had told them he was withdrawing from alcohol. We let the officer know that he was not, that his alcohol level was still over 200, and that he left 30 minutes ago ... [local police department] took him away with them, and they will try and find him a way back to Billings."

Review of patient #19's EMR provider note addendum dated 5/18/24 at 6:08 a.m., authored by staff member H showed, "patient #19 and law enforcement were informed by one of the staff that patient #19 had recently been discharged and his blood alcohol was 294, so he would not be going into withdrawals any time soon. Patient #19 left with law enforcement."

Visit #5: Patient #19 returned to the ED for a fifth time in three days, via ambulance. Patient #19's chief complaint was he thought he was having seizures.

Record review of patient #19's EMS report dated 5/18/24 at 12:30 p.m. showed a chief complaint of seizures. The medic's impression was substance-alcohol use/intoxication... "male patient did seem confused..." The heart rate documented on the EMS report was 129 bpm.

Review of patient #19's EMR showed patient #19 was triaged at 1:02 p.m., According to the nurse documented chief complaint, patient #19 stated, "I am having withdrawal from alcohol ...I think I am having a panic attack." Vital signs were obtained, and it was noted the patient had an elevated pulse of 129 bpm. Despite the tachycardia, the patient was assigned an ESI of 5 - non-urgent.

Record review of patient #19's ED record, completed by staff member J showed, "Patient called 911 today stating he thought he was having a seizure." Patient #19 stated the Salvation Army bought him a ticket to ride the bus back to Billings that evening, however the bus would not leave until 9 p.m. Patient #19 said he was worried he would not be able to make it until 9 p.m. without having a seizure from alcohol withdrawal. He stated he had one seizure approximately 4 years prior, which he believed was related to alcohol withdrawal.

Record review of patient #19's EMR, Medical decision-making showed, "Possible differentials include alcohol intoxication, drug use, anxiety, depression, malingering, at risk for DTs (delirium tremens, sudden and severe problems in the brain and nervous system, caused by alcohol withdrawal), seizure, dehydration, electrolyte abnormality, and worsening of a chronic condition ... He was given Ativan 1 mg (tablet) ... He is given an additional Ativan 1 mg (tablet) just prior to discharge." Patient #19 was discharged with a police officer to be taken to the bus station. No repeat blood alcohol level or lactic acid level was completed, and no repeat vital signs were found in the EMR, despite having an elevated heart rate on presentation and being administered medications (Ativan can lower blood pressure and respiratory rate).

Review of a facility policy titled, EMTALA- Emergency Medical Treatment and Active Labor Act, not dated, showed:
" ...An appropriate medical screening examination should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of on-call physicians and ancillary tests or services routinely available to the Hospital if needed to determine whether an emergency medical condition exists. The chart should document continued monitoring until the patient is stabilized or transferred ..."

Review of a facility policy titled, Suicide Risk Screening and Suicide Precautions for Patients, not dated, showed:
"Purpose: The purpose of this policy is to outline practices for the identification, assessment, and prevention of self-harm or attempted suicide by at risk patients during their emergency room visit or hospitalization ...
Suicide Risk Screening using the Columbia-Suicide Severity Rating Scale (C-SSRS):
All patients age 12 and older presenting for care in the Emergency Room...will have an initial suicide risk assessment completed upon admission using the Columbia-Suicide Severity Rating Scale (C-SSRS)....
Emergency Department (ED): Any patient presenting to the ED with a chief complaint of suicidal/homicidal ideation with intent or intent with a plan with the last month OR suicidal/self-harm behavior should be automatically placed on 1:1 observation until further evaluation can be completed. The ED nurse will perform the C-SSRS ... during triage to determine if a patient is at risk for suicide and if so, what level of risk they are.
High Risk (8+) ... 2. Order and initiate 1:1 observation and monitor for elopement risk. Document observations every 15 minutes. Staff must maintain direct observation at all times..."

Review of a facility policy titled, Signing Out Against Medical Advice- AMA, not dated, showed:
" ...2. The release of responsibility form will be signed by the patient before leaving ...
5. Staff will document medical record with details of the situation, regardless if the patient signed the AMA form or not."