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Based on observation, medical record review, and interviews, the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare Hospitals in emergency cases, when they did not complete a medical screening examination (MSE) for one of 20 (Patient #1) whose records were reviewed. Patient #1 was discharged from Facility A and called 911 while still on the facility property to report active suicidal ideation. [Police Department # 5] arrived at Facility A, where the patient was placed on an Apprehension by Police Officer Without Warrant (APPOW) for suicidal ideation. Patient # 1 was transferred from Facility A to Facility B. Patient #1 left Facility A via ambulance to seek treatment at Facility B, where he was admitted. At facility B, Patient # 1 was admitted inpatient for 1.5 days and place on suicidal precautions.


Refer to A2406

Based on observation, medical record review and interviews, the facility failed to complete a medical screening examination (MSE) for one of 20 (Patient #1) whose records were reviewed. Facility A did not complete a psychiatric assessment to determine if Patient #1 had an emergency medical condition and was not a danger to himself or others. Patient #1 was discharged from Facility A with "thought content that is paranoid and delusional." Patient #1 called 911 after discharge while still on the facility property to report active suicidal ideation. [Police Department # 5] arrived at Facility A, where the patient was placed on an Apprehension by Police Officer Without Warrant (APPOW) for suicidal ideation. Patient # 1 was transferred from Facility A to Facility B.
At facility B, Patient # 1 was admitted inpatient for 1.5 days and place on suicidal precautions.

Findings included:

Review Patient #1, Facility A - Visit 1

A review of the document titled "ED Provider Notes" completed by Staff # 4, the Physician Assistant in the Emergency Department on 03/30/2024 at approximately 9:02 AM revealed the following: "patient is a 41-year-old male with past medical history significant for bipolar, schizophrenia, polysubstance abuse presents to the emergency department via EMS for paranoia and chest pain. EMS reported that the patient was sitting at a gas station down the street when locals became concerned about the patient and called 911. EMS arrived and the patient complaining at that time of chest pain. He-had told the EMS personnel that he had been homeless for approximately 2 days with no other background information given at that time. The patient is with EMS and here in the emergency department is saying he has a "bug " inside of him and that people are listening to him. During the-interview and exam the patient is visibly upset and anxious appearing. The patient is a poor historian due to his emotional state at this time." ...
...Past Medical diagnoses: Bipolar 1 disorder, Psychiatric disorder and Schizophrenia.
During the Physical Exam it is documented the patient is, "Disheveled appearing, smells unkempt." ... "Speaking full sentences, no shortness of breath noted." ...
...Neurological:
"General: No focal deficit present.
Mental Status: He is alert
GCS: [Glasgow Coma Score measures consciousness] GCS eye subscore
is 4. GCS verbal[ response to questions] subscore is 5. GCS motor
subscore is 6[How the brain tells the body to move.].
Motor: Tremor (right hand shaking often) present. No weakness.
Psychiatric: Attention and Perception: He is inattentive. He perceives auditory hallucinations.
Mood and Affect: Mood is anxious. Affect is labile and tearful. Speech: Speech is rapid and pressured and tangential.
Behavior: Behavior is hyperactive.
Thought Content: Thought content is paranoid and delusional. Thought content does not include homicidal or suicidal ideation.
Cognition and Memory: Cognition is impaired. Judgment: Judgment is impulsive and inappropriate."
Remaining physical exam was unremarkable."

A review of the medical record revealed Patient #1 was an ambulatory discharged at approximately 11:30 AM with a diagnosis of methamphetamine abuse and paranoia. There was no documentation in the medical record to determine if the patient had an emergency medical condition for his psychiatric symptoms. There is no psychiatric evaluation, Columbia Scale or assessment of orientation noted prior to dischage. Patient #1 called 911 while still on the facility premises and report suicidal ideation. Police Department #5 arrived to the Facility A
Police Department # 5- Body Cam Timelines

A review of the transcript of the body cam of Officer # 1, and Officer # 2, revealed the following:
Video from Officer 1: (video time is represented in minutes)
00:00 - Video of ambulance bay, patient seen sitting on the ground, no staff around the patient, one officer (Officer 2) standing near him conversing, another officer (Officer 1) walking up with bodycam. Patient was heard talking but the words were undecipherable.
00:15 - Officer 2 asks, "What's your name pal?"
Patient 1 stated his name.
00:19 - Officer 2 repeated Patient 1's name and asked him, "What were you seen for here originally?"
Patient stated, "uh ...uh ...they picked me in front of ...uh ...uh"
00:22 - Officer 2, "They who?"
Patient stated, "uh ...the paramedics, they picked me up in Garland, I can't remember the name of ..."
00:26 - Officer 2, "Ok, but you came from Garland by ambulance?"
Patient 1 stated, "yeah and uh ..."
00:28 - Officer 2 asks, "What for?"
Patient stated, "I..I been up for a couple of days and ... uh ... I told them that ... and I was sweating real bad and uh, I was going through anxiety again and things in my head ...it's doing it again, and like I said they don't have no psych here so needed, like ..."
00:47 - Officer 2 stated, "They actually ...they do have psych here."
Patient 1 said, "He, they told me ...they brought me here but there like was no one I could talk to cause I was trying to explain that I need to get to a doctor so I can talk to him ... about the voices in my head, even when I been sober or not sober they are still there ....and I ...I need some help ... I need some help."
1:12 - Officer 2, "Ok."
Patient speaking incoherently ...
1:13 - Officer 2, "You said ...What's that?"
1:16 - A nurse, Nurse 1, comes out and asks Officer 1, "Is he coming back in?"
1:17 - Officer 2, "I assume so based on what he just told us."
1:19 - Patient 1 said, "I was trying to get to [facility # 1] or..or ...or, uh [facility # 2] to talk to a psychiatrist, cuz I was told y'all didn't have psych here."
1:27 - Nurse stated, "We are not a psych facility, we are happy to see you but he just asked you if had any suicidal thoughts ... you said no."
1:33 - Patient 1 said, "And, and I told him yeah and all I got was ...uh ...uh..and he sat in the chair and looked at me like I was stupid ...and ...and ...I ...and then ...I got discharge papers 15 minutes later. And I have no way to get to [facility # 1]or anything here cuz there's no bus route." - (Nurse was speaking to Officer 1 while Patient 1 is talking but it was undecipherable.)
1:47 - Nurse 1, "Ok."
1:50 - Patient, "And I don't know what, and I'm trying to go see a doctor, and ..." (Nurse 1 and Officer 1 talking in background.)
1:53 - Officer 2 said, "Sure. So, what the proper procedure is, since you are here, is to ...to be seen here and then they'll transfer you to an actual psych facility after ...after they their assessment on you ...ok? They have help here. It is true they don't have a full-blown psych unit here, that is true ...(Patient mumbling) I know, but that..that's the reason you are in a hospital and they will facilitate getting you there, ok and ...you are here for emergency services and so that's what they'll provide you while trying to get you in a stable environment." (Patient mumbling ...I don't, I don't ...etc. while Officer 1 is speaking.)
2:19 - Patient, "I don't ...I don't ...I don't feel safe outside ..."
2:23 - Officer 2 said, "I understand."
Patient, "I don't ...I don't ..."
2:25 - Officer 2 asks, "What's making you want to hurt other people?"
Patient says, "I don't wanna ...its myself ...it's hurting me ...I don't wanna hurt anybody ..."
2:32 - Officer 2 asks, "Yeah, I mean what's making you ...is there, are you hearing voices that are telling you to hurt other people?"
2:36 - Patient says, "No, I don't wanna hurt anybody, it's to hurt myself ... it's my ...I shoulda done it a long time ago ...I shoulda killed myself a long time ago ..."
2:44 - Officer 2 asks, "Why do you feel that way?"
2:46 - Patient says, "Because my life been shit ...(patient starts crying)
2:50 - Officer 2 asks, "When ...you ...you said you came in last night from Garland?"
2:55 - Patient says, "(stuttering and mumbling ...I called, I lived here, I tried to get a ride from somebody I know ...they can't come get me I know ...I tried to call non-emergency and they was closed or whatever, and then I they ...I just called 911 and my mother, she was just like (undecipherable) ...well y'all go there.."
3:16 - Officer 2 says, "I understand."
3:20 - Patient says, "I don't have no way in ...."
3:20 - Officer 2 says, "Ok. (Nurse talking) We ...we'll fill out an APPOW."
Nurse 1 said, ""That's fine"
3:24 - Officer 2 says, "Alright (patient name), well here is what we are going to do, ok. We're going to go back inside and were going to start getting them to help you, ok? And we will facilitate getting you some help, but the right process here is to start back in there and then we will get you to the right place."
3:35 - Patient says, "I don't want to stay ...I need to get to ...to a doctor ..."

Video Surveillance from Officer 2 body cam: (video time is represented in minutes)

0:00 - Patient is seen standing in ambulance bay of the facility talking to the approaching Officer 2. He was talking about the facility not having a psych facility and trying to get help. Patient is scratching his head, patting his head, sounds nervous and trembling is noted in his voice.
0:14 - Patient said, "I ...I ...I need to get to see a doctor. I need to go to, and they don't have a psych unit here, I need to get to [Facility # 1]or ...or [ facility # 2]or something I imagine ....(makes noise with his mouth)"
0:27 - Officer 2 say, "Ok. Um, do you mind setting your jacket down just so I can see ...make sure that you don't have anything on you?" (Patient drops his jacket, places his hands over his head, and backs up toward Officer 2)
0:37 - Officer 2 places Patient's hands on his head and ask", "Are the shakes new, or is that something that ...?
0:37 - Patient say, "No, I (undecipherable words spoke")."
0:41 - Officer 2 can be seen patting Patient down, then ask, "you've just got a phone, and just a normal wallet and what you got in here?"
0:54 - (undecipherable talk)
0:59 - Officer 2 said, "OK, you're good. Um ...If you don't mind just having a seat for just a minute ...Um ...What's your name?"
1:07 - Patient gives his name and begins sitting down on the curb in the ambulance bay. Officer is seen with a note pad and begins writing notes and Patient mumbles while he sits.
1:17 - Officer 2 said, "Spell it for me." Patient spells his name. There is clarifying talk back and forth between Officer 2 and Patient.
1:40 - Officer 2 asks Patient his DOB and writes it on the notepad. Patient is notably fidgety and anxious during the conversation.
1:54 - Patient says, "I just need... um, um to get a doctor so I can talk to him .."
1:57 - Officer 2 says, "ok."
2:08 - Patient says, "If there was a bus line I would be on it ...and I tried to call for a ride and I don't have one ...I don't (undecipherable) and I can't get a ride .."
2:15 - Officer 2 says, "Did you say that [Police Depart # 3]PD brought you here?"
Patient says, "um the paramedics"
Officer 2 says, "Ok."
Patient says, "um I don't know they just ...I was in [facility # 1] over there by the freeway somewhere, I don't know where the exact ..."
2:28 - Officer 2 says, "Where do you live?"
Patient says, "Right now I'm a, I'm homeless, I'm not ...I have nowhere to go, I was looking to get back into rehab and I fucked that up and now I just, I'm just having a mental breakdown because ...there's shit going on in my head and it's just (undecipherable ...)"
2:48 - Officer 2 says, "When you say you're having a mental breakdown, what do you mean?"
2:50 - Patient says, "It's the voices in my head and I want to hurt myself and all that and like I said, they don't have a psych unit here and all they could do is release me cuz all they don't have ...like psych departments, and ...and, like I told that lady, I just don't feel safe out here, I don't, not at all."
3:06 - Officer 2 says, "What are the voices saying?"
3:09 - Patient says, "They, ah, to hurt me, and I hurt myself and stuff..and I ...I ...I need to see a doctor ...I can't be out here, I don't I don't feel safe. (undecipherable) I get anxious and my and when I start shaking like this and the anxiety, and I ..."
3:40 - 8:04 - Officer 2 is joined by Officer 1 and the conversations are the same as in video 1 throughout 8:04, when the officers go separate directions. Officer 2 follows Patient into the room with Patient and Officer 1 completes paperwork at the nurse's station.
8:10 - Officer 2 says, "Hold on just one second, let him get to the bed dressed." The video shows a technician making up a bed for Patient.
8:29 - Technician says to Patient, "Ok, right there for me, sir." Technician points to the bed he just made. Technician says to Patient, "I am going to need all your things." Patient hands Technician his hand-held belongings. Technician says to Patient, "Can you empty out your pockets now for me?" Patient places items from his pockets on a bedside table.
8:46 - Patient says, "I am just wobbly." Patient is seen leaning onto bedside table. Technician says, "I understand, I understand."
9:00 - Technician requests a belongings bag from another technician.
9:03 - Patient says, "I just wanna get some help." Technician says, "Ok. Get right there on the bed for me."
9:10 - A male nurse walks in and says, "so you are wanting to kill yourself again, huh? Is that right?"
9:15 - Patient says, "Is it again?"
Male Nurse, "Yeah."
9:17 - Patient says, "Well I tried to tell y'all that earlier and all y'all told me is that y'all didn't have a psych unit and just gave me discharge papers."
9:21 - Male Nurse, "Yeah, we don't have it."
9:23 - Patient says, "OK, then I was told y'all was trying to get a department of whatever and I don't know who it was but he was saying that there was no way that y'all could do that. Yeah, we don't do that, that's what he told me. We don't do that, that's what he said." Nurse 1 walks in with an armband.
9:33 - Male Nurse, "Yeah, we don't transfer, yeah."
9:34 - Nurse 1, "Can you tell me if this is your right name and date of birth?" Patient reads the band and nods, then Nurse 1 says, "Let me see your arm so I can put on your bracelet." Patient holds out his arm and Nurse 1 places the armband on Patient.
9:40 - Patient says, "You know I just want to get to [facility # 1] ..."
9:43 - Male Nurse, "Why not stop doing drugs, that'll help."
9:47 - Patient says, "I explained that I was honest with everybody when I said that."
9:50 - Male Nurse, "Ok."
9:53 - Patient says, "I need (incoherent) when I am sober, too, and that's what to do."
9:56 - Male Nurse, "How do you want to kill yourself?" (There is a lot of traffic in and out of Patient room during this time with background conversations.)
9:57 - Patient says, "There's been plenty of times when I thought about cutting my own throat. I haven't done it, and when I was clean, I've been clean for one or two years ..." I've thought about jumping off a bridge when I was drunk." (There is a lot of traffic in and out of Patient room during this time with background conversations making transcription difficult.)
10:12 - Male Nurse, "Ok. What are you thinking about this time? Do you have a method (alarms beeping in background)"
10:13 - Patient says, "There's plenty of times I'd run out in traffic and same thing, jump off a bridge there's plenty of times ...I just want to go see a doctor and ..."
10:27 - Male Nurse, "Do you want to die?"
10:29 - Patient says, "Did I want to die, yeah, yeah, I wanted to die (There is a lot of traffic in and out of Patient room during this time with background conversations making transcription difficult.)"
10:38 - Male Nurse, "So what made you get help instead of acting on it?"
10:44 - Male Nurse, "Have you gotten help in the past for this?"
10:47 - Patient says, "Um ...I got on my meds, my ... I got off all my meds and I started drinking ... on the meds ...off the meds ...drink again ...I got sober, and I worked ...couldn't get off work to get back on my meds because my hiring supervisor was working me 12 hour days, so it was impossible ...." Patient continues speaking, but Officer 2 walks out of the room at 11:03 and conversation gets more difficult to understand. Officer 1 & Officer 2 meet up at 13:25 on this video and they exit.

Patient #1, Facility A-Visit 2

The facility continued documentation on the initial medical record for Patient #1 despite being discharged.
A review of the "ED Provider Notes" for Patient #1 completed on 3/30/24 at 1:07 pm by Staff #3 and emergency room medical doctor (MD) revealed, " ... [History of Present Illness]HPI 41 M returning to ER, now voicing suicidal ideation. Patient struggles with methamphetamine use disorder. Also has history of BPD [Bipolar Disorder]. He was seen earlier in the day for chest pain, shortness of breath, paranoia. Seemed to acutely be under the influence of methamphetamines. His work-up was normal/reassuring. He was discharged but never left the hospital grounds. He is requesting inpatient psychiatric treatment. He is hearing voices.
Past Medical History
Diagnosis
Bipolar 1 disorder (CMS/HCC)
Psychiatric disorder
Schizophrenia (CMS/HCC)"

A review of the "ED Course" for Patient #1 completed on 3/30/2024 at 2:21 pm by Staff # 2 & Staff #11, emergency room medical doctors (MD).
"Pt care signed out to me from previous ED Physician pending [Behavioral Health Evaluation] BHE for [suicidal ideation] SI, likely voluntary placement." -Staff #11
"1547 Discussed with BHC [Behavioral Health Connections], pt has Apprehension by Peace Officer Without Warrant (APOWW) at this time, wants inpatient treatment, they will Pursue [Order of Protective Custody] OPC at this time'" - Staff #11
"2322 Taking over patient care from preceding ER provider. Patient was evaluated early this morning for chest pain and paranoia' He was found to be methamphetamine positive was discharged. He never left the facility and called 911 stating that he was now suicidal. He was placed under an APOWW and brought back to the emergency department. He was medically cleared by Staff #12 and was evaluated by BHE [Behavioral Health Examiner . After his behavioral health evaluation, he is amenable to going to an inpatient psychiatric facility' Staff # 2 signed OPC paperwork. I have added on Tylenol and salicylate levels as they are the only lab work not collected prior to his behavioral health evaluation. He remained stable we will continue to monitor throughout my shift'".- Staff #11
"Sun Mar 31,2024
Discussed pt case with Transfer Center for Texas Health, they have bed ready for pt at [facility # 4]tomorrow' doc to doc with Facility B, Staff # 1 done - pending OPC and transfer tomorrow." - Staff #2

A review of the document tiled "Psychiatric Assessment" by Staff # 10, Licensed Master's Social Worker on 03/30/2024 at 3:55 PM revealed the following:
Patient # 1 reports suicidal thoughts and identifies his mother as a support person. Patient # 1 is homeless. Patient is alert an oriented to person, place, date and time, and circumstances. A level 1 care was recommended: "Inpatient level of care due to behavior that is imminently threating, destructive or disturbing to self or others."
Three places were recommended for transfer: [facilities #8, 9 and 10] Patient # 1 refused to sign the document.

A review of the document titled "Medical Decision Making" completed on 3/31/2024 at 2:11 am by Staff #3 revealed,
"41 M evaluated for symptoms of psychosis. Does have suicidal thoughts. Wants to get inpatient psychiatric treatment, voluntary. Medically cleared. I suspect psychotic symptoms may be attributed to methamphetamine use. Requested behavioral health evaluation. Anticipate attempting placement into inpatient psychiatric facility on a voluntary basis."

A review of the ED Notes by Staff # 13, RN-ED on 4/1/2024 at 12:41 PM revealed the following:
"Patient inquiring about leaving. States he doesn't want to go anywhere any longer. Informed patient he was here under order of protective custody and would have to stay for now."

A review of the document titled "ED Notes" by Staff # 9, RN-ED on 4/1/2024 at 8:00 PM revealed the following
"Transport here to take patient to facility. Pt refusing transport to facility. Charge Nurse notified. House Sup at bedside to speak with patient about his options. Transport has left d/t [due to] patient refusal. Pt now agrees to transport. Charge RN called transport to come back. Transport will return after completing next call."

A review of the document titled "ED Notes" by Staff # 9, RN-ED on 4/2/2024 at 12:25 AM revealed the following:

Patient #1 was transported via ambulance to Facility 4 for inpatient psychiatric treatment.

Review Patient #1-Facility B

Patient # 1 was a direct admit from [facility A]. Patient # 1 arrived on 04/02/2024 at 12:57 AM. Patient # 1 was placed on Suicide Precaution-Continuous with observation every 15-minute observation on 04/02/2024 at 0105. Patient # 1 was discharged from Facility B on 04/03/2024 at 7:46 AM. Condition was noted as stable.

A review of the document titled "Psychiatric Initial Assessment and Evaluation" by Staff # 1, Facility B, MD on 04/02/2024 at 7:52 AM reveals the following:
"I. Chief Complaint: "they said I was suicidal but I am not "
II. History of Present Illness: Patient is a 41-year-old Caucasian male has a history of depression and alcohol use. Patient states that "they said I was suicidal but I am not ". Patient states that "I was drunk". Patient states that he does drink heavy amounts of alcohol daily. States he can easily drink a 12 pack of beer. Reported his last drink was more than 4 days ago. States that "I am done detoxing now ". Patient states that "I am looking to get into a rehab center and they said I have to wait 2 weeks. " Patient this morning denies feelings of depression. Denies SI or HI."

A review of the document titled "Discharge Summary" by Staff # 2, LPC [licensed Professional Counselor] on 04/03/2024 at 10:45 AM revealed the following:
"Therapist met with patient individually to discuss discharge. Pt agreeable and acknowledged discharge plan. Pt denied SI. and denied HI. Pt declined ROI. Therapist unable to contact collateral for safety concerns. Therapist informed Staff # 1, MD and provider reports pt cleared to discharge. Pt will d/c to [facility # 7]Pt will be transported via Bus. Reviewed and updated safety plan with pt, pt voices understanding and agreement and will follow up with the following providers:
Discharge Plan for Patient # 1
Follow-up with your psychiatrist and substance abuse provider
Please present for walk-in intake assessment Wednesday April 4, 2024, at 8:00 am"




Policy Review

A review of the policy titled "Suicidal Ideation Risk Assessment" revealed the facility did not follow their own policy: page 1, Procedure 1.1 and 1.2
"1.1 A suicide risk screen is completed on every patient who presents to the Emergency Department, who presents to Behavioral Health, or is admitted to any inpatient area."
1.2 The Columbia-Suicide Severity Rating Scales (C-SSRS) will be used for screening and risk assessments; this includes school-age children and adolescents.
Patient # 1 did not receive a Columbia-Suicide Severity Rating Scales (C-SSRS) assessment on his initial arrival.
Interviews:

An interview with Officer # 1 on 05/15/2024 at approximately 7:24 AM revealed the following:
"We got a call from the patient telling us he was discharged from the facility and was in the back of the building and is suicidal. Dispatch called the hospital and informed them that officers were on their way for a suicidal individual and the location. I was hoping when we arrived the patient would be inside, but he was outside, near a camera. My partner and I wrote out an APOWW. I felt this would be the only way this individual would be taken care of. As I was filling out the paperwork, I could hear the nurse belittling him."

An interview with Staff # 2, MD-ED on 05/14/2024 at approximately 1:52 PM revealed the following:
When asked the process for patient that arrive with suicidal ideation, Staff #6 stated, "The room would be cleared of anything that could allow self-harm. The patient is provided paper scrubs. The patient waits for medical clearance and will be transferred to different facility for placement. Additionally, when asked if he would discharge a delusional patient he stated, "If a patient had delusions and they were safe it might be ok. We would make sure the patient did not have command hallucinations to harm. The patient might have conditions that at baseline they would have delusions or hallucinations."