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Based on interview, record review of the Emergency Department (ED) logs, 72 Hour Return logs, medical records, Staffing and Physician On-Call Schedules, the facility failed to provide two patients (#1 and #10) of 23 patients with a Medical Screening Examination (MSE) sufficient to determine the presence of a medical and or psychiatric emergency when the facility failed evaluate the patient's active hallucinations and to notify the patient's guardian prior to her imminent discharge and before she was allowed to leave unattended. The facility also failed to provide stabilizing treatment for an Emergency Medical Condition (EMC) within its capacity and capability for one patient (#19) of 23 patients when he was not admitted for psychiatric care and discharged to law enforcement.

Please see A2406 and A2407 for details.

Based on interview and record review, the hospital failed to provide a medical screening examination (MSE) sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for two patient (#1 and #10) who presented to the Emergency Department (ED) with psychiatric symptoms. Patient #1's guardian was not notified prior to or at the time of discharge from the ED. A total of 24 ED records were reviewed out of a sample selected from August 1, 2016 through February 7, 2017. The ED had an average of 3,914 emergency visits per month on the main campus and 2,331 emergency visits per month on the off-site campus.

Findings included:

1. Record review of the facility's policy titled, "EMTALA - Emergency Medical Treatment and Active Labor Act - Compliance," dated 06/10/15, showed that when an individual presents or is brought to the hospital for examination and treatment for an Emergency Medical Condition (EMC, defined by the facility to include psychiatric disturbances)
a medical screening examination (MSE) will be provided within the capability of the facility, including ancillary services routinely available.

Record review of the facility's policy titled, "Psychiatric Care," dated 12/23/16, showed:
- Any patient who presents to one of the hospital's EDs for psychiatric services, after clearance of the medical screening, will receive a psychiatric screening at the hospital's psychiatric center in the Assessment Unit (AU).
- Pediatric patients who present to the off-site ED unaccompanied will be transferred by Emergency Medical Service (EMS) and if the minor is accompanied by a guardian, will be transferred via private vehicle to the psychiatric center.
- When a presenting patient is determined to be at risk to harm self or others, who is medically unstable and unable to make clear decisions regarding his/her care, the patient will be identified as an acuity (method to categorize patients by priority to be seen/treated, based on the resources needed to stabilize or treat the patients) 2 Psychiatric P. Elopement precautions will be initiated during this evaluation period to determine the necessity for further intervention.
- Notification of provider caring for patient if patient makes comments or actions that suggest they may leave prior to the completion of the evaluation.
- A registered nurse (RN) can make the decision to place the patient in a restraint (violent).

Although requested, the facility failed to provide a policy related to guardian notification of patient care and/or discharge.

2. Record review of Patient #1's ED record showed that the patient presented by ambulance to the ED on 02/05/17 at 12:39 PM. Staff G, ED RN, documented that the patient was acting abnormally, disoriented, that the patient stated she was hearing voices and seeing things that were not there, and felt suicidal. Staff H, ED Resident Physician, documented a 12:40 PM examination, which included the patient's history of schizophrenia who resided at a long term facility (Facility 1), and who was "actively talking to people in the room who aren't there". Staff H planned for discharge of the patient, because he did not feel the patient was suicidal and because the patient "has known schizophrenia and is already at a long term facility". At 1:24 PM, Staff G, RN documented that she expressed concern to Staff H that patient should be seen by psychiatry, but Staff H continued plans to discharge of the patient. At 1:30 PM, Staff G documented that Facility 1 staff requested Patient #1 to be seen by psychiatry, which she communicated to Staff H, but Staff H talked with the facility staff on the phone, and per Staff H, the facility agreed to take the patient back without a psychiatric consult. At 3:30 PM, Staff G documented that the patient was discharged, but refused to return to Facility 1, and because she was not a psychiatric hold per Staff H, the patient was allowed to leave. At 3:32 PM, Staff G documented that she agreed with Facility 1's request for the patient to see psychiatry.

During a telephone interview on 02/15/17 at 2:00 PM, Facility 1 Licensed Practical Nurse (LPN) MM, stated that when she asked if Patient #1's psychiatric evaluation had been done, Staff G, ED RN stated that she was trying to get the attending to sign off on a psychiatric evaluation, but he would not do it. LPN MM stated that she informed Staff G that the patient had a guardian who would need to be contacted, and Staff G agreed that the guardian would be contacted before the patient was discharged.

During an interview on 02/08/17 at 4:51 PM, Staff H, ED Resident Physician, stated that when he assessed Patient #1, the patient was talking to people who were not there, but he didn't feel that a psychiatric consult was emergently necessary, even though the patient's nurse expressed concerns about the patient's suicidal thoughts. Staff H stated that he knew the patient had a history of schizophrenia and was on psychiatric medications, but did not know if the patient had been medication compliant. Staff H stated that he did not know if Patient #1 had a guardian and did not assume that the 34 year old patient who lived in a nursing home had a guardian, nor did he check the patient's medical record or paperwork provided by Facility 1 to find out. Staff H stated that Facility 1 requested that the patient receive a psychiatric evaluation, so he spoke with Facility 1's supervisor who "agreed" that the patient did not need one, and discharged the patient.

During an interview on 02/08/17 at 3:51 PM, Staff G, ED RN, stated that when Patient #1 arrived, the patient stated that she wanted to hurt herself, talked to the cardiac monitor, and when the patient's urine sample was removed from her room, the patient stated, "don't give me pickle juice". Staff G stated that Staff H, ED Physician worked up the patient for knee pain and discharged her back to Facility 1. "I advocated for the patient that she needed to go to the
psychiatric unit, because I felt she was making odd statements, (and her) schizophrenia was not controlled" but the physician felt she was safe to return to Facility 1. Staff G stated that Facility 1 inquired if the patient had received a psychiatric evaluation, so she handed the phone to Staff H, ED Physician, and he stated that the facility agreed to take the patient back without a psychiatric evaluation. Staff G stated that as the patient was discharged and escorted to Facility 1's transport van, the patient refused to get in the van, and left.

During an interview on 02/09/17 at 2:02 PM, Staff N, ED RN, stated that when she went to discharge Patient #1 "the patient didn't seem as if she would be able to comprehend the discharge instructions. She was bizarre, laying on the bed face down, non-cooperative and didn't want to go" and became 'angrier'. I was concerned that we weren't going to be able to get the patient on the van". Security responded, and when the patient began to run off, security regained control of the patient, but then released the patient because she was not a psychiatric hold, and the patient ran off down the street.

During an interview on 02/09/17 at 10:15 AM, Staff K, ED Attending Physician, stated that while he was with the patient, she had evidence of internal stimuli with auditory and visual hallucinations. Staff K stated that he did not know what the patient's baseline was or if she was medication compliant. Staff K stated that he was not aware if the patient had a guardian before he discharged the patient back to Facility 1 and added that if the patient had a guardian, she did not have the ability to decline her return to the Facility 1.

During an interview on 02/08/17 at 5:28 PM, Staff I, Resident Program Director, stated that physicians should contact the guardian and treat the guardian like a patient to acquire permission, update, and discuss disposition. Staff I stated that elopement should only be allowed if the patient was able to make decisions on their own. If the patient had a guardian, their ability to leave is not present because they are under guardianship.

3. Record review of a Psychiatry Call Schedule, dated February, 2017, showed a psychiatrist was on call 02/05/17, the day Patient #1 presented to the ED.

4. Record review of the Staffing Report for 02/05/17, showed there were nurses and mental health technicians staffed in the psychiatric AU on 02/05/17, the day Patient #1 presented to the ED.

During a telephone interview on 02/15/17 at 10:18 AM, Facility 1 Hospital Administrator F, stated that Patient #1 remained in the community overnight, but was incarcerated at the county jail with two felony assault charges after she threw hot coffee on a Law Enforcement Officer.

Patient #1 presented to the hospital with hallucinations, and possible suicidal ideations. The facility failed to provide a psychiatric assessment and failed to contact the patient's guardian, before the patient was allowed to elope from the facility.

5. Record review of Patient #10's ED medical record showed that she presented to the ED on 09/20/16 at 12:37 PM. She was triaged on 09/20/16 at 12:39 PM by Staff FF, RN. The patient's mother stated that the child saw things that were not there and reported that the patient recently had a tonsillectomy (removal of tonsils).
Staff CC, Physician (Resident) documented on 09/20/16 at 12:41 PM the following:
- Prior to this visit, Patient #10 saw bugs on her skin and in the room when they were not actually there. She was not actively hallucinating at time of exam. She heard her mother's voice at night and felt a crawling sensation on her skin.
- She had no self-injury. The mother also stated that the patient had "spells" when she stared. She would not respond to verbal stimuli. This was new for Patient #10. Her mother stated that she had no previous psychiatric history and had a tonsillectomy two weeks prior to this ED visit.
- The patient was alert, oriented to person, place, time, and situation.
- She was cooperative and her mood and affect were appropriate.
- An elevated white blood count (WBC) was related to her recent surgery. Her white blood cells were elevated in her urine, but likely not significant, especially in the absence of urinary symptoms.
- He had a detailed discussion with Patient #10's Mother about symptoms and follow-up on Monday with the primary care physician (PCP).
- This patient would benefit from further evaluation by a primary care and possibly psychiatry as well.
- Patient #10 was discharged to home on 09/20/16 at 4:41 PM with an appointment
scheduled with a primary care physician on 09/26/16.

During an interview on 02/14/17 at 3:48 PM, Staff CC stated that:
- He remembered the patient because the patient acted normal considering her chief complaint.
- She acted like a pediatric patient that did not need to be in the ED.
- She was not actively hallucinating, not depressed, or manic.
-"The girl talked to me about as much as a nine year old would."
-The girl explained very well what she saw and heard.
- He would typically admit a patient with these symptoms or call psychiatry across town.
- He and Staff DD talked with Patient #10's Mother extensively and she did not want to admit the child.
- Staff DD felt it was reasonable to discharge Patient #10, more so than he (Staff CC) did.
- Staff DD stated that patient did not have medical issues that would cause hallucinations.
- Patient #10's Mother wanted to follow up with the family physician so he felt it would be okay.
- He did not know if psychiatry would have accepted Patient #10.
- If you called the psychiatrist on call and the patient was accepted then the patient would be a direct admit to the AU unit on the main campus. If the psychiatrist on call did not accept the patient, then this facility would send the patient, needing a psychiatric mental health screening, to the ED and the patient would go through the ED process at the other campus hospital.
- He did sometimes overrule his Attending (physician) but it was not a common practice. If he had continued worries and the mother had worries, then he might have pushed harder for an admission.
- Six days out was more than he would have preferred for a follow-up visit with the PCP, but he was aware of the date of the appointment and the PCP had seen Patient #10 in the past.
- Patient #10 did not hear voices that told her to hurt herself or anyone else.
- He had never let anyone go home that was suicidal (SI) or homicidal (HI.)

During an interview on 02/14/17 at 4:41 PM, Patient #10's Mother stated that:
- The staff performed lab tests and talked with her.
- The hospital suggested that she might get some psychiatric help for Patient #10, but did not offer a mental health screening or a psychiatric consult. She stated the facility did not treat this issue with her daughter as it was serious.
- The physician came in and said the lab test results were negative and she should seek psychiatry assistance and they sent them home.
- The Resident (Staff CC) asked the patient if she had ever thought about suicide or if the voices told her to harm herself. She denied having suicidal thoughts or the voices telling her to harm herself.
- She was willing for Patient #10 to have a mental health screening or be admitted.
- Patient #10 was eventually seen by the PCP and was referred to a psychiatrist.
- Hallucinations continued for Patient #10 even with weekly psychiatric sessions.

During a telephone interview on 02/16/17 at 8:41 AM, Staff DD, Physician, stated that:
- Patient #10's Mother was concerned about hallucinations the patient had and the patient had a recent tonsillectomy.
- The patient denied active symptoms at the time. She previously saw things and felt things on her skin.
- The mother said this had occurred recently for several days and had occurred over the last month or two.
- Some of the history was from the patient and he felt it was creditable.
- He stated that when it comes to hallucinations with pediatric patients the vast majority are not psychiatric related, but typically, stress related or organic (medical issue).
- Patient #10 was not acute from a psychiatric stand point.
- Her labs were within defined limits and she was medically stable.
- The patient was assessed for immediate danger and for any SI and HI. Patient #10 had no risk due to SI or HI so she could follow up with the PCP and psychiatry.
- Patient #10 was assessed for SI and HI, but it was not documented.
- Patient #10 did not have any emergent psychiatric issues and he would not typically call psychiatry to rule that out.
- He and Staff CC discussed the possibility of an emergent psychiatric consult, but Staff DD did not recall Staff CC specifically saying he felt this patient needed to be seen by psychiatry.

6. Record review of the documents titled, September 2016 - Psychiatry Call/Moonlighting schedule showed on 09/20/16 there was Psychiatry available.

The facility failed to do a complete psychiatric medical screening exam, by not contacting psychiatry for consultation.




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Based on interview, record review and policy review, the facility failed to stabilize an Emergency Medical Condition (EMC) for one patient (#19) of 23 patients who presented to the Emergency Department (ED) seeking care for an emergency medical or psychiatric condition, out of a sample selected from August, 2016 through February 7, 2017. The ED had an average of 3,914 emergency visits per month on the main campus and 2,331 emergency visits per month on the off-site campus.

Findings included:

1. Record review of the facility's policy titled, "EMTALA - Emergency Medical Treatment and Active Labor Act - Compliance," dated 06/10/15, showed an individual who presents with an Emergency Medical Condition (EMC, defined by the facility to include psychiatric disturbances) will receive further medical examination and treatment within the capabilities of the staff and facility as may be required to stabilize (defined by the facility as no material deterioration is likely to occur from the emergency medical condition).

During a telephone interview on 02/15/17 at 8:44 AM, Probation and Parole Officer II stated that on 12/01/16, Patient #19 went to a behavioral health clinic (non-hospital related clinic) for an emergency psychiatric appointment (prior to arrival to the ED at 4:28 PM) because he was having a very hard time. When he presented, he was highly agitated, homicidal, and threatening, and stated he wanted to kill someone with a knife. The entire clinic was put on red alert due to the risk he presented. Law Enforcement was called, and he was taken to the hospital ED because the patient was completely out of control. Prior to transport, the patient was found with a knife in his possession, which was removed by law enforcement.

2. Record review of Patient #19's ED record showed the patient presented to the ED on 12/01/16 at 4:28 PM, with complaints of suicidal ideation (thoughts of killing self) and homicidal ideation (thoughts of killing others), and had been off of his psychiatric medications "a couple weeks". Staff AA, ED Physician documented that the patient stated that he had a gun and planned to use it on his roommate who had stolen his medications. The patient, a diabetic, also stated that he had a suicidal plan to stop eating and die from hypoglycemia (low blood sugar). The patient complained of auditory hallucinations (hearing things that are not there) with voices telling him to hurt people, and added that he was dangerous, had killed several people in the past, and was a child molester. The patient's documented history included schizoaffective disorder (mental disorder in which a person experiences a combination of hallucinations or delusions, and depression or mania) and antisocial personality disorder (mental health condition in which a person shows no regard for right and wrong, and ignores the rights and feelings of others). The patient was found to be "medically cleared", and was sent to the psychiatric center's Assessment Unit (AU, located away from the ED, but on the same campus) for evaluation at 9:20 PM, with a plan to "admit to inpatient" to the psychiatric center. On 12/01/16 at 11:49 PM, the patient signed an application for voluntary inpatient admission (was not admitted to inpatient) to the psychiatric center and at 11:51 PM, an order was given for the patient to be observed for suicide.

During an interview on 2/09/17 at 4:47 PM, Staff U, ED Registered Nurse (RN) stated that Patient #19 stated that he was suicidal, had been off his medications, and talked about a gun.

During a telephone interview on 02/16/17 at 7:30 AM, Staff LL, ED Resident Physician, stated that Patient #19 had a flat affect, stated that he had a gun at his house and would use the gun (would not divulge on whom), and with his diabetes history, threatened to stop eating to die. The patient was transferred to the psychiatric center after he was medically cleared.

During a telephone interview on 02/10/17 at 8:45 AM, Staff X, ED Resident Physician, stated that while in the main ED, Patient #19 admitted that he had suicidal and homicidal thoughts, admitted that he had a gun, and seemed anxious, so the patient was sent to the psychiatric center (separate location from the ED,same campus, which has an the AU, Extended Emergency Room, EER, and inpatient units) and became the responsibility of the psychiatric center physicians.

3. Record review of a Psychiatric Admission Assessment dated 12/01/16 at 10:09 PM, documented by Staff W, Psychiatric Center AU RN, showed that the patient continued to have homicidal thoughts, with a history of previous suicide attempts, and was at risk for suicide based on multiple psychiatric diagnoses. During the assessment, the patient was loud and refused to provide information, demanded to see the psychiatrist, and talked about using a gun to kill the person who stole his medication.

During an interview on 02/09/17, at approximately 5:45 PM, Staff W, Psychiatric Center AU RN, stated that when Patient #19 came to the AU, he was not cooperative. He was loud, angry, and demanded to talk to the psychiatrist. He was upset and stated that he would kill the guy that stole his medications from his truck, and talked about using a gun.

4. Record review of a Psychiatry Consult Note dated 12/02/17 at 12:53 AM, showed that the patient "endorsed" (stated or declared) suicidal thoughts and homicidal thoughts with access to a gun, poor sleep, loss of interest, and decrease food intake. He complained of racing thoughts, flights of ideas and impulsivity (to act on a whim), anxiety with excessive worrying and feelings of impending doom, panic, delusions and hearing voices. His violence risk assessment included a history of two arrests, one for attempted murder and one for a terrorist threat, and stated that he would kill people if he was discharged. During his mental status exam, the patient was aggressive and non-cooperative with poor grooming. He exhibited agitation with tense, rapid speech, was angry, with a disorganized, loose thought process. His insight and judgment was limited. The patient was to be admitted to the EER, (once the patient is assessed in the AU, the patient may need further observation or to wait for an inpatient bed and will stay in this unit; admission is observation only) to monitor mood and behavior and plan to discharge him when he is "able to provide collateral sources of information".

During an interview on 02/09/17 at 3:40 PM, Staff R, Psychiatric Center Resident Physician, stated that although Patient #19 stated he was suicidal and homicidal, "I didn't agree with him".

5. Record review of a Psychiatric Notes addendum dated 12/02/16 at 10:34 AM by Staff T, Psychiatric Resident, showed that the patient had been rude and demanding, was "fed up" due to suicidal and homicidal ideations, was tearful and stated that he was "super depressed". He continued to have homicidal ideations with stated access to a gun, and intention to "hunt him (roommate) down". The plan for the patient was to "continue stay in EER as he may not be admitted to the (adult psychiatric) unit due to history of making bomb threats to the hospital".

During an interview on 02/09/17 at 4:16 PM, Staff T, Psychiatric Center Resident Physician, stated that she was informed Patient #19 could not be admitted to the hospital due to a previous bomb threat, so she kept him in the EER because she felt the patient wasn't safe to be discharged and was a threat to himself and/or others, because he was tearful, depressed and continued to have homicidal ideations.

6. Record review of a Psychiatric Notes addendum dated 12/02/16 at 3:16 PM by Staff BB, Resident Psychiatrist, showed that the patient reported feeling overwhelmed and wanted help and continued to make threats about getting his gun and hurting people. Staff BB documented that he spoke with the patient's parole officer, who advised that law enforcement would come and get the patient, and the patient would be discharged to law enforcement.

During an interview on 02/10/17 at 9:16 AM, Staff Y, EER RN, stated that she prepared Patient #19's discharge paperwork (on 12/02/16), and when the patient found out that he was being discharged, he called his parole officer
and his Parole Officer didn't feel Patient #19 was appropriate to be discharged.

During a telephone interview on 02/15/17 at 8:44 AM, Parole Officer II stated that on 12/02/16 at 11:00 AM, he received a call from Patient #19 (while at the psychiatric center), who was screaming and homicidal, and threatened to get a gun and start mass shooting people, and made threats that he was going to kill a homeless man, and then shoot Parole Officer II. Parole Officer II contacted the psychiatric center's psychiatrist, explained the threats that the patient made, and hoped they would reconsider keeping the patient in the hospital, but the hospital responded "he makes these threats often" and that they were not a homeless shelter. "I received some unofficial reports from the psychiatric center nurses that they felt he was stable and thought he just wanted three hot meals and somewhere to stay for the night." Parole Officer II stated that she requested they delay the patient's discharge, contacted hospital police, hospital security, and city police. "I was frustrated by the entire thing because he was making threats and (the psychiatric center) was saying that he just does this because he wants a place to stay. I could not rest with him in the community. That's why we put the warrant (probation violation related to having a knife in his possession at Behavioral Health Clinic 1) out for his arrest." The patient was placed in the custody of law enforcement, and remains in the county jail. Parole Officer II stated that the patient has a history of two counts of making terrorist threats against the hospital. He called and left a voicemail with (bomb) threats on 10/06/15. The patient also has a 2nd degree assault charge. "It would not surprise me if he had killed people."

7. Record review of physician orders dated 12/02/17 at 1:46 PM, were to discharge the patient to law enforcement. At 1:53 PM, the patient was discharged to jail, escorted by law enforcement.

8. Record review of the Adult Psychiatric Adult 1 and Adult 2 unit census for 12/01/16 and 12/02/16, showed there were 12 beds available for inpatient admission on 12/01/16 and 13 beds available for inpatient admission on 12/02/16, the days Patient #19 presented for psychiatric care.

9. Record review of the psychiatric centers staffing for 12/01/16 and 12/02/16, showed there were nurses and mental health technicians staffed in the psychiatric inpatient and outpatient psychiatric units.