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Based on document review and staff interviews, the hospital failed to provide a medical screening exam for 1 patient (#1) who presented to the emergency room requesting care, out of 50 cases selected for review from December 2009 to May 2010. The hospital emergency room staff identified an average of 2094 emergency room visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of the policy # EMS-E-0030, "EMTALA and the Psychiatric Patient", revised 8/07, revealed in part on page 6, "For any individual who comes to the ED ... on whose behalf a request for examination or treatment for a psychiatric condition is made, an appropriate medical screening examination shall be provided by a Qualified Medical Professional within the capabilities of the ED ... to determine whether or not an emergency psychiatric condition exists. For individuals with psychiatric symptoms, the medical record shall indicate that there was an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates a danger to self or others as set forth below."

2. According to the policy, # EMS-P-0340, titled "Psychiatric Patient Care - Suicidal Patient Care", last revised 1/07, the procedures staff follow include: "1. Patient should be undressed completely upon arrival to ED and placed in hospital scrubs or gowns without ties. Pockets should be emptied and personal belongings documented and bagged, and placed in a safe location.... 4. DO NOT leave patient unmonitored at any time. Patient could inflict personal injury. 5. Obtain history from patient or family to include, but not limited to: ... medical history, previous suicide attempts, patient's emotion and pattern of behavior prior to the suicide attempt or threat...."
3. Review of the medical record revealed the ED Triage nurse A handwrote on 4/7/10 a list of patient # 1's diagnoses, which included PTSS (Post Traumatic Stress Syndrome) on the "ED Triage Nursing Assessment" form. Under "Comments", nurse A handwrote "attempt 1981 - Etoh - pulled car in garage running, Suicidal thoughts, Anxious." At 1:52 PM, on a form titled "Clinical Report - Nurses" nurse A documented the triage exam, obtained patient #1's vital signs, and specified patient #1's chief complaint was "SUICIDAL THOUGHTS." Under "History" nurse A noted that patient # 1 "has had anxiety and describes feelings of depression." Under "Past Medical History" nurse A documented that patient # 1 presented to the ED from patient #1's physician's office accompanied by an office nurse and that the office nurse would stay with patient # 1 in the lobby, until "family arrives." The medical record did not contain any documentation indicating an ED physician or other "Qualified Medical Professional" examined patient # 1. 4. During an interview on 5/13/10 at 4:00 PM, office nurse D confirmed that patient # 1 presented to the physician ' s office in the afternoon on 4/7/10 complaining of feeling bad and expressed thoughts of self harm. Office nurse D stated she asked patient # 1 to explain his thoughts. Office nurse D stated that patient # 1told her that he had previously attempted suicide by turning on the car engine while in the garage with the door closed. Office nurse D stated that patient # 1 told her that a few days before coming to the physician ' s office he started having thoughts of self harm again. Office nurse D confirmed she escorted patient # 1 from the physician ' s office to the ED out of concern for patient #1's safety. Office nurse D stated that she explained to ED nurse A who she was, where she was from, and that patient # 1 had thoughts of self harm and needed to be seen. Office nurse D stated that ED nurse A asked her to wait with patient # 1 in the waiting room and estimated she stayed with patient # 1 15 - 20 minutes, and without warning, he left the ED and she could not find him. 5. Review of a second medical record revealed patient # 1 returned to the ED on 4/7/10 at 3:03 PM (approximately 1 hour after triage) via the hospital owned and operated ambulance. According to the ambulance report, patient # 1 suffered a traumatic head injury from a gunshot wound. The ED physician examined patient # 1 in the trauma room and documented patient # 1 ' s home medications included drugs for the treatment of diabetes, high blood pressure, depression, anxiety and a severe mental disorder. At 4:42 PM, an air ambulance arrived at the ED to transport patient # 1 to Hospital B (Level 1 trauma center) where he later died.

6. During an interview on 5/13/10 at 1:05 PM, Physician C, the medical director of the ED, stated patient #1 did not receive a medical screening exam. Physician C stated that patients with suicidal ideations are immediately taken to a room or a supervised area and never left alone. Physician C stated the ED finds a way to prioritize patient with suicidal ideations. Physician C stated that if there is a patient with a minor complaint, especially if they are just waiting for results, we would move them to another room [to allow the patient with suicidal ideations to be brought back]. " Physician C stated that if patient # 1 told the ED nurse that he was having suicidal thoughts, " he should have been brought back and supervised [by our staff] and prevented from leaving. " " If they had been conveyed [suicidal thoughts] he would have been brought back and wouldn ' t have been left in the mix in the waiting room. "

The hospital failed to follow their policy, and did not provide an appropriate medical screening exam to a patient (#1) who had a psychiatric emergency. Refer to tag A-2406 for further details.

Based on document review, and staff interview, the hospital failed to provide a medical screening exam for 1 patient (patient #1) who presented to the emergency room requesting care out of 50 cases selected for review from December 2009 to May 2010. The hospital emergency room staff identified an average of 2094 emergency room visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed patient #1 first presented to the Emergency Department (ED) on 4/7/10 at 1:45 PM. ED Triage nurse A handwrote on 4/7/10 a list of patient # 1's diagnoses, which included PTSS (Post Traumatic Stress Syndrome) on the "ED Triage Nursing Assessment" form. Under "Comments", nurse A handwrote "attempt 1981 - Etoh - pulled car in garage running, Suicidal thoughts, Anxious." At 1:52 PM, on a form titled "Clinical Report - Nurses" nurse A documented the triage exam, obtained patient #1's vital signs, and specified patient #1's chief complaint was "SUICIDAL THOUGHTS." Under "History" nurse A noted that patient # 1 "has had anxiety and describes feelings of depression." Under "Past Medical History" nurse A documented that patient # 1 presented to the ED from patient #1's physician's office accompanied by an office nurse and that the office nurse would stay with patient # 1 in the lobby, until "family arrives." The medical record revealed no documentation that an ED physician or "Qualified Medical Professional" examined patient # 1.


2. During an interview on 5/14/10 at 8:45 AM, RN A stated patient #1 presented to the ED accompanied by a nurse from patient #1's physician's office. RN A stated the nurse with patient #1 told her that patient #1 complained of suicidal ideations and of having "bad thoughts". RN A stated all the emergency room beds had patients in them, and requested the office nurse remain with patient #1 in the waiting room until his family arrived, since RN A did not feel comfortable with patient #1 being left alone.

3. During an interview on 5/14/10 at 12:40 PM, the ED Nurse Manager stated that patients with suicidal ideation are placed in ED room 8, a room directly across from the nurse ' s station allowing for easy observation of the patient. The ED Nurse Manager stated that room 8 had been specially arranged so psychiatric patients can safely sit in the room without access to items they could use to harm themselves, " if we can ' t put a patient in room 8 we put the patient in a room where the nurses have direct line of sight into the room. "


4. During an interview on 5/13/10 at 1:50 PM ED nurse E confirmed that patients expressing suicidal ideations " should be taken back right away " and are placed in room 8 across from the nurse ' s station, " it is a monitored room. " ED nurse E stated that the mental health liaison comes to the ED and evaluates the patient for stability and psychiatric placement.

5. During an interview on 5/13/10 at 1:05 PM, Physician C, the medical director of the ED, stated patient #1 did not receive a medical screening exam. Physician C stated that patients with suicidal ideations are immediately taken to a room or a supervised area and never left alone. Physician C stated the ED finds a way to prioritize patient with suicidal ideations. Physician C stated that if there is a patient with a minor complaint, especially if they are just waiting for results, we would move them to another room [to allow the patient with suicidal ideations to be brought back]. " Physician C stated that if patient # 1 told the ED nurse that he was having suicidal thoughts, " he should have been brought back and supervised [by our staff] and prevented from leaving. " " If they had been conveyed [suicidal thoughts] he would have been brought back and wouldn ' t have been left in the mix in the waiting room. "


6. Review of a second medical record revealed patient # 1 returned to the ED on 4/7/10 at 3:03 PM (approximately 1 hour after triage) via the hospital owned and operated ambulance. According to the ambulance report, patient # 1 suffered a traumatic head injury from a gunshot wound. The ED physician examined patient # 1 in the trauma room and documented patient # 1 ' s home medications included drugs for the treatment of diabetes, high blood pressure, depression, anxiety and a severe mental disorder. At 4:42 PM, an air ambulance arrived at the ED to transport patient # 1 to Hospital B (Level 1 trauma center) where he later died.