HospitalInspections.org

Based on review of facility policy, review of an Emergency Department (ED) log, review of facility surveillance videos, review of a policy department report, medical record review, and interview, the facility failed to ensure a medical screening exam (MSE) was completed for 1 patient (Patient #1) who presented to the ED with Suicidal Ideation of 33 ED patients sampled.

The findings include:

Refer to A-2406

Based on review of facility policy, review of an Emergency Department (ED) log, review of facility surveillance videos, review of a police department report, medical record review, and interview, the facility failed to ensure a medical screening exam (MSE) was completed for 1 patient (Patient #1) who presented to the ED with Suicidal Ideation of 33 ED patients sampled.

The findings include:

Review of Facility A's policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), last revised 2/5/2021, showed "...Comes to the Emergency Department [ED] means an individual who: has presented at a hospital's dedicated emergency department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. A request on behalf of an individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition; is on hospital property (including parking lot, campus, ambulance bay, and other departments of the hospital)...and requests examination or treatment for what may be an emergency medical condition (or has such a request made on their behalf)...Emergency Medical Condition (MSE) means...With respect to an individual with psychiatric symptoms: That acute psychiatric or acute substance abuse symptoms are manifested; or That the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others...When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED (including ancillary services routinely available to the ED), shall be provided to determine whether an emergency medical condition exists...MSE shall be performed by qualified medical personnel (QMP), who may be an ED physician or other licensed practitioner appointed and approved by the Hospital's Medical Staff and Board of Trustees..."

Review of an ED "Unregistered Patients Log" dated 2/13/2021 at 10:55 PM showed Patient #1 presented to the ED with a complaint of "Suicidal."

Review of facility video surveillance recordings at Facility A dated 2/13/2021 from 9:50 PM until 10:28 PM (correct time was 10:50 PM-11:28 PM video surveillance recordings were off by 1 hour) showed the following:
9:50 PM - 9:51 PM (video camera located at the ED entrance) Patient #1 entered the ED, was screened for COVID-19, and then proceeded to the ED registration desk. The registration clerk spoke with Patient #1 and then handed the patient a form to complete. The patient pushed the form back toward the registration clerk and left the ED without completing the form. An ED employee followed the patient outside and returned to the ED after a few seconds without the patient.
9:52 PM -The ED charge nurse stepped outside the ED.
9:55 PM - An ED employee and a Security Officer walked outside.
9:56 PM - (video camera located in the ED parking lot) a Security Officer approached Patient #1's vehicle; several hospital staff were also observed on video standing at a distance from the patient's car.
9:57 PM - the Security Officer backed away from Patient #1's vehicle.
10:05 PM - A Police Department Officer arrived at the facility and interacted with Patient #1.
10:09 PM - A 2nd Police Department Officer arrived at the facility.
10:26 PM - Both Police Department Officers drove away from the facility.
10:26 PM - (video camera located at the ED entrance) The House Supervisor and the Security Officer returned to the ED.
Review of the video cameras showed Patient #1 did not returned to the ED.

Review of a police department report dated 2/13/2021 at 11:04 PM showed a police officer was dispatched to Facility A for a patient with a suicide attempt. The officer's report stated, upon arrival at the facility Patient #1 was sitting in the driver's seat of a vehicle holding a 6-inch knife to his stomach and yelling "...Shoot me! Shoot me..."

Review of the ED medical records at Facility A dated 2/13/2021 showed there was no medical record completed indicating Patient #1 was triaged by nursing staff or received a MSE by a QMP.

Medical record review at Facility B showed Patient #1 was transported by police to the ED on 2/14/2021 at 12:45 AM after the patient was found in Facility A's parking lot with a knife to his abdomen threatening to kill himself. The ED physician's history and physical showed "...They [law enforcement] attempted to have him [Patient #1] treated at [Facility A's] emergency department...were told that they [Facility A] did not have sufficient security resources to evaluate him...no medical screening exam was performed and he was brought from their [Facility A's] campus to our hospital campus...When I enter the room the patient is in 4 point restraints...He is combative and threatening towards myself and everyone in the room. He is encouraging us the kill him as he wants to die...[Patient #1] put a pillowcase around his neck and twisted the pillowcase to tighten it around his neck..." Patient #1 was transferred to a behavioral health facility from Facility B on 2/15/2021 with diagnoses including Suicidal Ideation, Acute Psychosis, and Acute Alcohol Intoxication.

During a telephone interview on 2/25/2021 at 4:18 PM, the House Supervisor at Facility A stated she received a call from the ED stating there was a man in the ED who was going to kill himself. The House Supervisor stated that upon her arrival to the ED Patient #1 was in the parking lot cussing at staff and the police were around him. She stated the police told her the patient had not stabbed himself and he was not bleeding. The House Supervisor did not assess the patient. The House Supervisor confirmed Patient #1 was not evaluated by a physician at Facility A prior to leaving with the police.

During a telephone interview on 2/25/2021 at 4:45 PM, Registered Nurse (RN) # at Facility A stated the registration clerk told him Patient #1 came in the main ED entrance with a knife and was going to kill himself. RN #1 stated he observed Patient #1 outside in the parking lot for a short time, but then he went back inside the ED to care for his other patients. RN #1 did not assess the patient and stated to the best of his knowledge Patient #1 was not evaluated by a physician at Facility A.

During a telephone interview on 2/25/2021 at 5:04 PM, the ED Charge Nurse at Facility A stated Patient #1 came into the ED and said he was going to kill himself. The Charge Nurse told staff to call security and the police department. The Charge Nurse stated she went outside to assess the patient, but he would not let her touch him. She stated the police officer tried to get the patient to go inside the ED, but the patient got more violent. The Charge Nurse stated she told the police officer the patient could be evaluated at Facility A, but the police said "...absolutely not..." because Facility A did not have armed guards and that the patient needed to be seen somewhere else because he was violent. The Charge Nurse did not advise the police officer that the patient had to have a MSE before he could be taken to another facility. Continued interview confirmed Patient #1 did not return to the ED and a MSE was not performed by a QMP.

During a telephone interview on 2/25/2021 at 5:10 PM, the Registration Clerk at Facility A confirmed Patient #1 presented to the ED on 2/13/2021 and during the registration process the patient provided his name and date of birth but refused to provide any further information. The Registration Clerk stated Patient #1stood up and said he was going to kill himself, then exited the ED before the registration process was completed.

During a telephone interview on 2/25/2021 at 5:45 PM, Physician #1 at Facility A stated he was in the process of preparing to intubate another patient when he was told there was a stabbing in the parking lot. After he finished the intubation, Physician #1 asked what had happened to the stabbing victim and was told the patient was in the parking lot. Physician #1 stated "...if he [Patient #1] is on property...need to see him...I never went out there...he never came in..."

During a telephone interview on 2/26/2021 at 10:30 AM, Security Officer #1 stated he located Patient #1 outside in the parking lot inside of a vehicle with a knife to his stomach. He stated he attempted to get the patient to go inside to get help, but the patient told him "...I'm going to kill you and myself..." The security officer stated the police officer said since the security officers at Facility A weren't armed with weapons, they (police officers) were going to take the patient to Facility B. Security Officer #1 stated he never told the police officers the facility did not have sufficient security resources to evaluate Patient #1.

During a telephone interview on 2/26/2021 at 10:55 AM, Police Officer #1 stated Patient #1 had a knife to his abdomen when he arrived on scene at Facility A's parking lot. Police Officer #1 stated the patient was not under arrest, but he was detained under Title 33 (Tennessee State law used to detain someone who is a danger to self and others). Police Officer #1 stated he transported the patient to Facility B because Facility A did not have armed security officers.

During a telephone interview on 3/1/2021 at 9:40 AM, the Chief Quality Officer at Facility A confirmed a MSE by a QMP was not completed on Patient #1.