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Based on interview and review of Emergency Department (ED) logs, Medical Records and Policy the hospital failed to
provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within its capacity and capability for three patients (#28, #4 and #9) of 30 ED records reviewed from October 2016 through March 2017.

The hospital failed to sufficiently evaluate Patient #28's "worsening" mental health status, including her frequent head banging, escalating and demonic auditory hallucinations, increased nervousness/anxiety and worsening insomnia. The facility failed to prevent elopement of Patient #4 by not providing continuous monitoring and adequate oversight and failed to sufficiently evaluate Patient #9's bipolar disorder and thoughts of suicide.

Please see the citations at A2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide a sufficient Medical Screening
Examination (MSE) to determine the presence of a psychiatric Emergency Medical Condition (EMC) within its capacity and capability, for three patients (#28, #4 and #9) of 30 Emergency Department (ED) records reviewed from October 2016 through March 2017. The hospital failed to sufficiently evaluate Patient #28's "worsening" mental health status, including her frequent head banging, escalating and demonic auditory hallucinations, increased nervousness/anxiety and worsening insomnia. The hospital failed to prevent elopement of Patient #4 by not providing continuous monitoring and adequate oversight, and failed to sufficiently evaluate Patient #9's bipolar disorder and thoughts of suicide. The hospital's failure had the potential to affect all patients who presented to the ED. The ED sees approximately 3567 patients per month. The facility census was 194.

Findings included:

1. Review of the facility policy titled "Emergency Medical Treatment Labor Act," (EMTALA) revised 08/2016, showed:

- All patients presenting to the Emergency Room requesting an examination or treatment for a medical condition must be given a Medical Screening Exam (MSE).
- If that exam reveals that the patient has an Emergency Medical Condition (EMC), the patient must be provided medical care and treatment to stabilize their medical condition.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances (such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.

2. Review of Patient #28's medical record showed the following:

-The patient arrived at the Emergency Department (ED) on 03/23/17 at 11:20 PM with a family member with complaints of hearing voices, "but worsening over past 2 weeks."
-Triage acuity (nurse will evaluate the patient's condition and will determine their priority for treatment in the Emergency Room) was a one on a scale of one to five (one being the most emergent).
-The Suicide Risk Assessment showed the patient denied plans for harming herself or others but "wants the voices to stop."
-Staff placed the patient in ED Room #14, the psychiatric safe room, a room without equipment to prevent the patient from self harm.

Review of ED Registered Nurse (RN) L's nursing assessment, showed the following:
-Thought process: "Auditory hallucinations." Documentation by ED nurse L showed that Patient #28 reported that sometimes she hears voices but for the past two weeks she had been hearing "demonic voices constantly" and wanted the voices to go away.
-Sleep pattern: Documentation showed that the patient reported a normal sleep pattern but "I just can't do anything during the day."

At 1:25 AM Patient #28 underwent a CT brain scan (special type of x-ray) due to a history of "trauma." ED physician G determined the results of the CT brain scan were normal.

At 2:36 AM, ED Physician G completed an examination of Patient #28 and documented the patient presented to the ED with escalating auditory hallucinations (hearing things that are not there) over the past 2 weeks. Documentation showed the patient stated that the "ice might be spirits are communicating with her." "In order to get 'him' to stop, she has been banging her head on the wall frequently." Further documentation by ED physician G showed that patient # 28 had an "altered mental status", "behavior changes and confusion", "her condition was worsening", the patient was "not taking medications as prescribed", and that the patient was "nervous/anxious." Further documentation showed the patient had an elevated blood pressure 132/100 (normal 120/80) and a rapid heart rate of 110 (normal adult heart rate at rest is 60 - 100 beats per minute).

The medical record did not contain evidence the patient received an examination sufficient to determine the presence of an emergency medical condition. Documentation showed that the patient's hallucinations were increasing in frequency and had been constant over the past two weeks. In order to get the demonic voices to stop, the patient would bang her head against the wall frequently. There was no evidence in the medical record to indicate a definite plan to coordinate psychiatrc care for patient # 28 prior to or after discharge, and left that up to the patient and her family. The medical record did not contain evidence the patient's demonic hallucinations and self-injurious head banging would cease or even decrease. The hospital had the capabilities to obtain further evaluation and psychiatric services for patient #28 but did not.

At 2:44 am, ED physician G diagnosed patient # 28 with psychosis (out of touch with reality and is a symptom of a serious mental disorder) and wrote orders for discharge. The discharge instructions included adivce to follow-up with your psychiatrist, and to "Get Prompt Medical Attention if any of the following occur": "Extreme restlessness or irritability"; "Confusion or hallucinations (seeing or hearing things that are not there)"; "Anxiety, depression"; "Several days without sleeping." At 2:43 am patient # 28 departed the ED with a prescription for Ativan (an anti-anxiety medication).

Review of the hospital provided form, undated and signed by ED nurse L showed the following:

-The patient denied any suicidal ideation and denied attempts at harming herself.
-The patient stated that she had been hearing voices for two years but was hearing "demonic voices constantly for the past two weeks."
-The patient stated she was having trouble sleeping.
-The patient stated that her "medications just aren't working."
-The patient was directed to return if her condition/symptoms changed or worsened.

During an interview on 04/04/17 at 3:14 PM, ED nurse L stated that neither the patient nor her mother ever made any statements regarding self harm (documentation in the medical record indicated patient # 28 underwent a CT scan of the brain due to "trauma" from the patient banging her head against a wall to try and get the demonic voices to stop).

During an interview on 04/04/17 at 10:30 AM, ED physician G, stated that the patient presented with the complaint of hearing voices. He stated that the patient denied suicidal or homicidal ideation. He stated that the patient said very little and that the mother answered the majority of his questions. He stated she was under the care of a psychiatrist and would follow up with the psychiatrist. He stated that as he as leaving the room, the patient mentioned that she was having trouble sleeping and he prescribed lorazepam (Ativan) until she could see her psychiatrist.

During a telephone interview on 04/10/17 at 10:30 AM, Patient #28 stated that she sought care at Hospital B after discharge because the voices in her head were getting worse. She stated that she was told to go to Hospital B if she needed further treatment because they had a psych unit. She didn't remember who told her.

Review of patient # 28's medical record from Hospital B showed the patient presented at 3:13 am, approximately 30 minutes after discharge from Saint Francis on 3/23/17. Documentation in the medical record showed that patient # 28 was admitted for treatment of a psychiatric emergency.

3. Review of the facility's ED's policy titled, "Suicide Risk Assessment," revised 06/2014 showed if a patient was determined to have suicidal or homicidal ideations a suicide risk assessment was completed. A suicide risk score of greater than 12 directed that the patient was determined to be at risk for suicide, placed on 1:1 observation and immediately taken into the treatment area.

Review of the facility policy titled, "Guidelines for Utilization of Patient Safety Attendant," dated 07/21/05 showed that the patient safety attendant program was developed to assist in providing a safe environment for patients while reducing utilization of restraints and for observation of a suicide patient. The patient safety attendant's responsibility with suicidal patients was to continuously observe and stay within no less than six feet of the patient.

4. Review of Patient #4's medical record showed that he presented to the ED on 10/16/16 at 4:39 AM by private car with complaints of suicidal thoughts. Staff assigned the patient an acuity level of two (Emergent), which indicated a high risk situation.

Review of the ED Triage Assessment by ED nurse L, on 10/16/16 at 4:46 AM showed:
- He was given a suicide risk score of 23 (a score of 12 or greater indicated that the patient was placed on suicide precautions);
- Patient Acuity level of two; and
- ED destination to ED Room #14.

Review of the initial ED psychosocial assessment by ED nurse AA, on 10/16/16 at 5:00 AM showed:
- Patient was ambulatory with a steady gait;
- He appeared anxious and irritable but cooperative;
- He was assessed as having a high risk of suicide (risk score of 23);
- He was placed on suicide precautions; and
- He had a suicide plan, he "wants to kill himself somehow."

Review of ED Physician N's documentation showed:
- The patient presented to the ED suicidal and asked the physician "are you the one who is going to kill me" when ED physician N walked into the room;
- The patient informed ED physician N that he tried to get the "Cop" to shoot him but instead the cop dropped him off at the hospital;
- The patient stated that two weeks prior, his children's mother accused him of threatening her and now his children have been taken away from him and full custody has been given to her;
- He attempted to stab himself until his wife called the cops;
- He noticed that the cops were there and he pointed a knife at them like a gun, hoping they would shoot him;
- Patient had previous episode one year ago and he tried to kill himself with rat poison.
- The patient's past medical history included anxiety and depression.
- Documentation showed the patient was nervous and anxious.

Review of ED nurse E's psychosocial assessment dated 10/16/16 at 7:53 AM showed:

- Patient # 4 was restless but cooperative;
- Patient # 4 had a plan for suicide or harming others;
- Patient # 4 had a history of previous suicide attempts in the past year; and
- Patient # 4 had a high risk of suicide.

Review of Social Worker Z's notes dated 10/16/16 at 10:56 AM showed:

- She was referred to assist patient # 4 who was verbalizing suicidal ideation;
- After arrival to the ED, the patient became agitated and stated he just wanted to go home and follow up with a physician on outpatient basis;
- Patient # 4 stated (to the physician) that if the physician discharged him he would kill himself before he got home;
- The physician ordered patient to be involuntarily court ordered for mental health treatment at another hospital;
- Hospital C accepted the request for transfer;
- Staff obtained a court order for an Involuntary Hold; and
- The local sheriff's department was contacted to provide transport to Hospital C.

Review of the Application to the Court for a 96 Hour Detention showed patient # 4 was brought to Saint Francis Medical Center ED by another county sheriff's department for evaluation and treatment after he verbalized suicidal ideations and threatened to stab himself. The court order was signed by Social Worker Z and a Notary of the Public.

Review of the Court's Order showed it was signed by a judge and dated 10/16/16 and that Patient # 4 would be transported to Hospital C for treatment.

Review of the hospital document titled, "Cobra Patient Transfer Form," dated 10/16/16 at 10:20 AM showed:
- Physician's certificate for transfer for an EMC;
- Diagnosis: Suicidal ideation, depression;
- Reason for transfer: Specialty care;
- Benefit of transfer: Appropriate treatment;
- Risks of transfer: Deterioration in route;
- Involuntary Committal;
- Transfer Acceptance Information: Hospital C as receiving hospital;
- RN from Hospital A to RN at Hospital C report; and
- Transfer of service by local sheriff's department.

Review of the ED nurse E's reassessment of Patient #4 on 10/16/16 at 1:00 PM showed:
- Continued plan for suicide or harming others;
- Ideation only;
- Suicide precautions; and
- Patient in view of nursing station.

Review of ED nurse E's nursing notes dated 10/16/16 at 1:05 PM showed that the patient ran out of the ED and nurse E was unable to stop him after multiple attempts. Police notified that the patient ran out of the department.

During an interview on 04/06/17 at 9:45 AM, Social Worker Z stated that court orders for involuntary commitment were obtained only after placement has been found at a receiving facility.

During an interview on 04/06/17 at 10:05 AM, ED nurse E stated that:
- He was the day shift nurse for Patient #4 on 10/16/16;
- The patient was agitated when he came on duty and security was called to come and stand at the patient's doorway until he calmed down;
- Staff obtained a court order for the patient to be involuntarily admitted to Hospital C for inpatient treatment;
- The local sheriff's department had been called by Staff Z at 10:40 AM to come and pick up patient;
- ED nurse E could see patient # 4 in his room while seated at the nursing station;
- Patient # 4 was getting restless while awaiting transport to Hospital C;
- The patient ran out of his room and down a hallway, exited the ED and down another hallway to an outside exit; turned left and ran down a hallway;
- The patient was dressed in a hospital gown and had no shoes on; and
- ED nurses stayed within three to four feet of a patient who was placed on 1 to 1 observation.

Observation on 04/06/17 at 10:20 AM of the ED showed:
- Behavioral Health Room #14 was approximately 18 feet from the nursing station where ED nurse E was seated when Patient #4 ran out of his room;
- It was approximately 70 feet from Room #14 to the door that exited the ED;
- It was approximately 200 to 300 feet from the ED exit door to the door that exited the building into the garden area.

During an interview on 04/06/17 at 11:05 AM, the ED Medical Director stated that Patient #4 had 1:1 observation and that meant that the nurse only had that patient and that nurse was to remain in close proximity to the patient. He stated that he did not know when the hospital's EMTALA obligation ended with ED patients.

During an interview on 04/06/17 at 11:25 AM, ED Nurse Manager stated that a 1:1 observation indicated constant supervision within three to four feet proximity to the patient.

Review of the local police department document titled, "Incident Details" dated 10/16/16 showed that the hospital called them at 1:09 PM indicating patient # 4 had left the ED "against medical consent." The report indicated that patient # 4 was never found.

The evidence in the medical record showed the hospital failed to re-evaluate patient # 4 when ED nurse E noted the patient becoming anxious while waiting for transport to Hospital C. Further evidence showed that the hospital's failure delayed further examination and treatment of patient # 4.

5. Review of Patient #9's medical record showed that he presented to the ED on 01/09/17 at 8:00 PM by car complaining of suicidal thoughts.

Review of the Triage Assessment by Staff DD, RN showed:
- Patient was suicidal with plan and/or harm to others;
- History of suicide attempts within past one to five years;
- Suicide risk score of 11 (a score of 12 or greater placed a patient on suicide precautions); and
- Elevated blood pressure of 149/101 (normal range 120/80).

During a telephone interview on 04/12/17 at 1:13 PM, ED nurse DD stated that:
- She was the triage nurse for Patient #9 on 01/09/17 and that he presented with suicidal thoughts;
- The patient scored an 11 on the suicide risk assessment but since he presented with suicidal thoughts that automatically placed him on suicide precautions;
- It was the facility's process to keep a psychiatric patient in the ED if there was no available bed for placement until a bed became available; and
- She cannot recall any suicidal patient being discharged if there was no available bed for placement.

Review of the Nursing notes and psychosocial assessment documented by ED nurse BB on 01/09/17 at 8:20 PM showed:
- Patient # 9 stated that his mother had kicked him out of her house;
- He had no exact plan for suicide at this time;
- He had been off of his psychiatric medications for eight months and would like to be in a treatment facility to get back on his medications; and
- Patient # 9 had a suicide risk score of 11.

During an interview on 04/12/17 at 11:40 AM, ED nurse BB stated that:
- Patient #9 said he was suicidal upon arrival to the ED on 01/09/17;
- The social workers were the ones who attempted to find placement for patients;
- If placement/available bed was not found for patients who were suicidal, the patients were held in the ED until a bed became available;
- Prior to Patient #9's arrival in the ED he had been found sleeping within the hospital by security and was told he needed to leave if he had no reason to be there;
- She felt the patient was not suicidal at the time of discharge. That she had spoken to his mother earlier by phone and it was okay for him to come back home.

Review of ED Physician CC's documentation on 01/09/17 at 9:54 PM showed:
- The patient was kicked out of the house by his mother;
- He had no plan but had suicidal thoughts for the past three days and he knew if he didn't get help he might act on the thoughts;
- Earlier in the day he and his mother's boyfriend had gotten into an argument;
- He had been out of prison for eight months;
- He had tried to hang himself while in prison;
- He felt like nobody cared and that his life was worthless. He could not get a job because he was a convicted felon;
- The patient had a past medical history that included anxiety, bipolar disorder, depression and high blood pressure;

Review of documentation by Social Worker Y dated 01/10/17 at 12:25 AM showed:
- She was consulted because the patient complained of suicidal thoughts;
- All psychiatric facilities were full and had current waiting list; and
- The ED physician was to review the plan for the patient's hospital admission.

Further documentation showed the patient spoke only a few minutes and then shut his eyes and would not continue speaking with the social worker. The patient admitted to suicidal thoughts "although does not have a plan." The social worker documented attempts to find a psychiatric inpatient bed at six different hospitals. However, all of them were full and had waiting lists.

During an interview on 04/06/17 at 9:30 AM, Social Worker Y stated that there were no psychiatric beds available for Patient #9 on 01/09/17. Social Worker Y stated whenever this occurred, the ED physician would re-evaluate the patient to see if they could formulate a safe plan for discharge. Social Worker Y stated that it was the physician's decision whether to keept the patient at the hospital until a psychiatric inpatient bed became available or to discharge the patient.

At 12:47 AM, the ED physician documented the patient's mother did not want him out on the street, and that he could come home. Further documention showed the patient "is happy with plan and has no plans to hurt or kill himself or others." "He had stated earlier he messed up earlier." "Patient being discharged."

The medical record did not contain evidence that patient # 9 received an examination sufficient to determine whether or not an emergency medical condition existed. The ED physician discharged patient # 9 prior to obtaining a psychiatric evaluation and despite having made statements regarding suicidal thoughts that were quite concerning.


















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