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Based on record review and interview, the hospital failed to ensure compliance with all Emergency Medical Labor and Treatment Act (EMTALA) requirements under 42 CFR 489.20 and 42 CFR 489.24. This facility failed to initiate an appropriate transfer for one of eight patients(Patient #1) who presented to the Emergency Department (ED) in a mental health crisis in a sample of 20 medical records reviewed; and failed to ensure that one of eight patients(Patient #1) who presented to the ED with a mental health crisis received a full medical screening exam per facility policy that included suicide and homicidal risk that indicates a danger to self or others in a sample of 20 medical records reviewed.

Findings include:

1) The hospital failed to ensure that one of eight patients(Patient #1). who presented to the ED with a mental health crisis received a full medical screening exam per facility policy that included suicide and homicidal risk that indicates a danger to self or others in a sample of 20 medical records reviewed. Reference A2406

2) The hospital failed to initiate an appropriate transfer to a specialized care mental health facility for one of eight patients (Patient #1) who presented to the ED with a mental health crisis in a sample of 20 medical records reviewed. Reference A2409

Based on record review and interview the facility failed to ensure that one of eight patients (Patient #1) who presented to the Emergency Department (ED) with a mental health crisis received a full medical screening exam per facility policy that included suicide and homicidal risk that indicates a danger to self or others in a sample of 20 medical records reviewed.

Findings include:

Facility policy titled "EMTALA: Screening, Stabilization and Transfer" dated 12/2015 was reviewed on 10/10/18 at 9:15 AM. This policy states "Behavioral Health Patients. The Medical Screening Examination should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates a danger to self or others. Such information must be documented in the medical record."

Review of Patient # 1's history and physical note dated 9/25/18 by Medical Provider E at Hospital J revealed patient #1 had a "history of schizophrenia and bipolar disorder. Patient was picked up by Police officer and chapter 51 (police custody hold for a mental health crisis in which a person may not have the capacity to make their own decisions) hold was placed in that county. Patient was seen in a local Emergency Room in the area and vitals and urine drug screen were completed without acute finding. Patient reportedly refused all blood draws at that time. Per police who are with [Name of Patient #1] now there was a very long process involving definitive medical clearance, and a decision was made to transport to [Name of Hospital L] without labs being drawn. [Name of Hospital L] refused admission upon arrival citing lack of these labs for medical clearance, and so they present to our Emergency Room for evaluation. [Police officer from police department K] is with the patient. Patient does not comply with exam or history." Physical examination revealed in part "...psych: mood and affect are agitated, uncooperative, at times appears to be responding to internal stimuli." History and Physical also states "Patient agitated but continuing to refuse further evaluation." There is no evidence in the medical records of an assessment for suicide or homicidal risk or whether the patient was a danger to self or others per facility policy.

During an interview on 10/10/18 at 10:30 AM. with Dr. E, Dr E stated the Emergency Room received a call from Hospital L's medics stating they were coming from Hospital N because Hospital N refused to admit the patient. When the patient arrived the patient was escorted with an EMT (emergency medical technician) and police with a Chapter 51 hold from another County. Dr. E stated based on assessment, evaluation and observation of the patient the patient did not have a medical emergency except for mental health. Dr. E stated "the patient was medically cleared..." Dr. E stated there was no other course of action for the patient other than to discharge into police custody, which is a secure location for the patient to be held after the patient was cleared of no other medical emergency.

Based on record review and interview, staff at this facility failed to initiate an appropriate transfer to a specialized care facility for one of eight of 8 patients (Patient #1) who presented to the Emergency Department (ED) in a mental health crisis in a sample of 20 medical records reviewed.

Findings include:

Patient #1's medical record was reviewed on 10/10/18 at 11:00 AM.

Review of Patient #1's record revealed Patient #1 arrived at Hospital J on 9/25/18 at 4:29 PM. At 5:05 PM it states "Patient standing in hall threatening staff. Patient states 'there is no way in hell I'm going in there'. Patient continues to threaten staff. Patient moved to room 9. One officer and loss prevention staff member in room with patient. Patient unwilling to be assessed. Does not want to be evaluated." At 6:28 PM record states "Patient refusing care at this time. [Police Department I] at bedside. Will continue to monitor."

Medical Provider E's history and physical note dated 9/25/18 at Hospital J revealed patient #1 has a "history of schizophrenia and bipolar disorder. Patient was picked up by Police officer and chapter 51 (police custody hold for a mental health crisis in which a person may not have the capacity to make their own decisions) hold was placed in that county. Patient was seen in a local Emergency Room in the area and vitals and urine drug screen were completed without acute finding. Patient reportedly refused all blood draws at that time. Per police who are with [Patient #1]now there was a very long process involving definitive medical clearance, and a decision was made to transport to [Hospital L]without labs being drawn. [Hospital L]refused admission upon arrival citing lack of these labs for medical clearance, and so they present to our Emergency Room for evaluation. [Police officer from police department K] is with the patient. Patient does not comply with exam or history." Physical examination revealed in part "...psych: mood and affect are agitated, uncooperative, at times appears to be responding to internal stimuli." History and Physical also states "Patient agitated but continuing to refuse further evaluation. I had a long conversation with [police sergeant from police department K], with [Hospital J's] legal, RN spoke with [crisis center M], and I spoke with [Hospital L]and [Hospital N]. Consensus was that given duration of symptoms with only apparent medical emergency being [Patient #1's] mental health we did not have a legal right to chemically restrain the patient in order to draw lab work, and patient was discharged back into police custody with plan for transport back to [Police department K]. There is obvious risk in any transport of an agitated psychiatric patient, and given duration of distance this is compounded, but given legal advice, amount of chapter restrictions, and patient wishes, a safer plan was not an option." Patient #1 was discharged into police custody at 7:20 PM.

Reviewed an additional 19 emergency room records. Of these 19 records Patient # 11, 12, 13, 16, 17, 18, 19, and 20 were patients in mental health crisis. All of these cases were transferred to inpatient mental health facilities with either police escort or both police and EMS (Emergency Medical Services) escorts. Patient #1 was discharged into police custody with no transfer initiated to an appropriate facility for continued mental health crisis.

Facility policy titled "Behavioral Health Patients and the emergency detention and or protective placement process" dated 6/30/2016 was reviewed on 10/10/18 at 1:00 PM. This policy revealed "4.2 Patients's who are under involuntary detention will be transferred with acceptance of County Behavioral Health resource and law enforcement upon receiving medical clearance." This policy also states " 5.2 Upon medical clearance, determine where police intend to take the patient. a) if patient is under a Chapter 51 or Chapter 55 detention, contact the appropriate County department."

During Conducted an interview with Dr E on 10/10/18 at 10:30 AM. Dr E stated the Emergency Room received a call from Hospital L's medics stating they were coming from Hospital N because Hospital N refused to admit the patient. When the patient arrived the patient was escorted with an EMT (emergency medical technician) and police with a Chapter 51 hold from another County. Dr. E stated the Chapter 51 stated the patient could not be restrained or forced and the paperwork stated the patient had the right to refuse all medication and treatment except by court order. Dr. E stated the patient did not have a court order. Dr. E stated legal counsel was involved and the conclusion was that the patient was not physically harming self or other therefore, the patient had the right to refuse the blood draw and forcing the patient with medication to draw the blood was not ok. Dr. E stated based on assessment, evaluation and observation of the patient the patient did not have a medical emergency except for mental health. Dr. E stated "just because the mental health facility wanted blood drawn does not mean we can force non-emergent medical treatment on (the patient)." Dr. E recalled having talked to the Crisis Center M, Police department K and Police department I. At that point the patient was calm and roomed without incident and did not warrant any emergency medication. Dr. E stated "the patient was medically cleared and did not feel the labs were needed to indicate clearance based on patient history and assessment." Per Dr. E the patient was in the Emergency Room for four to five hours of observation. Dr. E spoke with the Chief of Police from police department K and stated there was nowhere to send the patient that would accept. The decision was made to discharge the patient back into police custody. Dr. E stated "the patient was medically stable outside of the psychiatric emergency. Police custody is secured custody. The police facility is a secured facility and can watch for suicide until further admission was found." Dr. E spoke with Attorney and ethics expert towards the end of patient #1's emergency department visit and was advised at that point they had a secure and safe location for the patient to go and was advised they could not force the patient into any other treatment without a court order. Dr. E stated there was nowhere else to safely discharge the patient. Dr. E spoke with Hospital N's nurse manager to try and facilitate a transfer without the lab draw and Hospital N's nurse manager stated they needed the lab draws for admission per their medical director and would not accept any patient without the labs. Dr. E stated the labs they were requesting were a Complete Blood Count, Alcohol blood content, acetaminophen levels, acetylsalicylic acid levels, urine drug screen, Thyroid stimulating hormone, and basic urine analysis. Dr. E stated the medications to sedate the patient were ordered but later discontinued and never given per the advice of ethics council. Dr. E spoke with the police I who stated they could not be involved unless the patient became actually violent. Dr. E also spoke with the Police K and the EMT (Emergency Medical Technician) that accompanied the patient regarding the legalities of forcing medication and blood draw. The County Crisis center M was contacted but stated they could not help with patient because the patient was Chapter 51 in another county who now had the jurisdiction/burden for placement. Dr. E stated this facility did not look elsewhere for placement of the patient because Hospital L already did this including contacting the Administrative Representative about placement issues and the State official couldn't help. Dr. E stated Hospital L tried to find placement for over 24 hours and eventually discharged the patient into police custody. Dr. E stated police K were told Hospital N could not refuse the patient when they initiated transport to Hospital N. Dr. E stated there was no other course of action for the patient other than to discharge into police custody, which is a secure location for the patient to be held after the patient was cleared of no other medical emergency.

During an interview with President A on 10/18/18 at 9:10 AM, President A stated this patient case was discussed with an ethics committee that night, as well as, an independent attorney who specializes in ethics. A stated this patient case was also discussed with internal council at the time of the incident. All parties agreed it was unethical to force medication on the patient as a means to restrain the patient to draw blood.

Conducted an interview with Director of Risk Management H on 10/10/18 at 9:45 AM. Director H stated they were the house supervisor and received report of the situation with Patient #1 in the Emergency Room. Director H went to the Emergency Room approximately 5:30 PM on 9/25/18. Director H stated Patient #1 was in the Emergency Room escorted by police from police department K, and an EMT and three police officer from police department I and one security officer from the facility. Director H spoke with Dr. E and read the paperwork for the Chapter 51 hold and seen that the patient had the right to refuse and be free from restraint. Director H placed a call to the Vice President of Risk and it was recommended that Director H call Ethics Attorney F. Director H also contacted Hospital L to confirm no labs had been drawn there. Director H stated H spoke with Hospital L's emergency room manager who confirmed no labs had been drawn. Director H spoke with Ethics Attorney F and reviewed the Chapter 51 language. Director H spoke with Dr. E who felt it was in the best interest to sedate the patient and draw the labs. Director H stated Ethics Attorney F, as well as Aurora's legal counsel, advised them that they did not have the right to sedate the patient if the patient was being cooperative and non-violent. Director H advised Dr. E to contact Hospital N and try to get them to accept the patient. Director H also stated H spoke with the Crisis Center M who was unable to find placement for the patient. Director H stated at that point the Police chief K was instructing the police officer and EMT to bring the patient back to Police Department K. Director H stated Hospital J questioned that, but the consensus was that with the support of an EMT enroute, along with police presence they felt it would be safe to discharge the patient with that type of support. The Police Chief K initiated the return of the patient to police department K.

Interview with Emergency Room Social Worker G on 10/10/18 at 10:45 AM revealed that Social Worker G did not have any involvement with Patient #1 and could only speak to the standard protocols in this situation. Social Worker G stated the normal process is to help with bed placements for voluntary patients. For Chapter 51 placements the County Crisis Team is responsible to find placement for the patient and treatment planning. The patient is then transferred to the accepting facility found by the Crisis Team usually with police escort.