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Based on review of facility policy, medical record review, review of Emergency Medical Services Prehospital Care Reports, and interviews, the facility failed to provide an appropriate ongoing medical screening exam (MSE) and failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the Emergency Department (ED) with Altered Mental Status, of 32 ED patients reviewed.

The findings include:

Patient #1 presented to the ED on 12/13/2021 at 8:55 AM and stated "...I'm a drug addict. I need help..." The mode of arrival was documented as "...walk in..." The patient's urine drug screen (UDS) was positive for benzodiazepines and THC (marijuana). Patient #1 attempted to elope from the ED twice by walking toward the exit doors. The patient was placed on a 6401 hold (process used to detain an individual for mental health examination). Patient #1 was given Geodon (antipsychotic medication) and fell asleep. When the patient awoke, she bolted out of her room and eloped from the ED. The police department brought the patient back to the ED but the patient refused to go back into the ED. The patient was placed on a 6404 hold (also known as a certificate of need [CON] - a legal document used in the involuntary commitment process for individuals posing an immediate substantial likelihood of serious harm due to mental illness or serious emotional disturbance based on the face to face examination of the person by a qualified professional) and was transported to the jail to await mobile crisis evaluation and placement at a psychiatric facility. Patient #1 was transported from the jail to the ED on 12/15/2021 at 11:15 AM after she experienced what was thought to be a seizure in the jail. The patient's UDS was negative for benzodiazepines. A CT (computerized tomography-detailed x-rays) of the patient's head was performed and showed no abnormalities. Patient #1 was transported back to the jail to await psychiatric placement. Patient #1 was transported from the jail to the hospital on 12/15/2021 at 6:32 PM after experiencing a seizure at the jail. Patient #1 was actively seizing upon arrival to the ED, her airway was compromised with decreased respiratory effort, she was cyanotic (bluish discoloration) and sweaty. Patient #1 was intubated (breathing tube) and was admitted to the Intensive Care Unit.

Refer to A-2406 and A-2407.

Based on review of facility policy, medical record review, review of Emergency Medical Services (EMS) Prehospital Care Records, and interviews, the facility failed to provide an appropriate ongoing medical screening exam (MSE) for 1 patient (Patient #1) who presented to the Emergency Department (ED) with Altered Mental Status, of 32 ED patients sampled.

The findings include:

Review of the facility's policy "EMTALA [Emergency Medical Treatment and Labor Act]-Medical Screening and Treatment of Emergency Medical Conditions" effective 6/2020 showed "...Emergency Medical Condition [EMC] means...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment of bodily functions; or Serious dysfunction of any bodily organ or part...The Hospital must provide for an appropriate Medical Screening Examination conducted by a physician or other QMP [qualified medical provider], including to the extent necessary ancillary services within the Hospital's capabilities and on-call physician services, to determine whether or not an Emergency medical Condition exists...Provision of the MSE is required regardless of the Hospital's size...A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer...The Hospital may move the patient to other Hospital-owned facilities that are on-campus or contiguous [sharing a common border, touching] to the Hospital in order to access appropriate services as part of the MSE or subsequent stabilizing treatment...Patients should not be moved to off-campus departments of the Hospital in the course of the MSE...If the MSE reveals an Emergency Medical Condition, the Hospital must provide stabilizing treatment within its capacity and capabilities (including on-call physician services and ancillary services) necessary to stabilize the patient or must appropriately transfer the patient to another facility. Admission as an inpatient may be required as part of the stabilizing treatment..."

Medical record review of ED nurses notes showed Patient #1 presented to the ED as a "walk-in" on 12/13/2021 at 8:55 AM and stated "...I'm a drug addict. I need help..." The patient was triaged as a level 3 (nonurgent) on the Emergency Severity Index (ESI) system (a 5-level system used to categorize ED patients). Continued review showed Patient #1 received Geodon (antipsychotic medication) 20 milligrams (mg) intramuscular (IM) at 9:19 AM, Potassium Chloride (electrolyte replacement) 40 milliequivalents (mEq) by mouth (PO) at 11:25 AM, and Rocephin (antibiotic) 1 gram IM at 10:53 AM. Patient #1 was discharged to police custody to "...hold at jail to wait for mobile crisis placement [to psychiatric facility]..." on 12/13/2021 at 11:33 AM (2 hours 38 minutes after arrival).

Medical record review of laboratory results dated 12/13/2021 at 9:45 AM showed Patient #1's urine drug screen (UDS - used to test for presence of drugs) was positive for THC (marijuana) and benzodiazepines (medication used to treat anxiety).

Medical record review of ED Physician documentation showed Patient #1 received a medical screening exam (MSE) by a qualified medical provider (QMP) on 12/13/2021 at 8:56 AM. The patient presented to the ED with "...psychosis [severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality], has experienced auditory hallucinations [perception of hearing something not present], has experienced visual hallucinations [perception of seeing something not present], a history of substance [drug] abuse, Polypharmacy [multiple drugs] per pt [patient]..." Patient #1's exam showed "...Behavior/mood is anxious, aggressive, delirious, Affect is animated, Oriented to person, place, time, Patient has no thoughts/intents to harm self or others. Judgement/Insight is impaired. Delusions/hallucinations are present and described as Visual, seeing deceased father in flowers on birdcage; Auditory, hearing deceased family members talking to her. NO COMMAND VOICES [voices instructing patient]..."

Medical record review of ED Physician Documentation dated 12/13/2021 at 11:24 AM showed Patient #1 attempted to leave the ED twice while she was on a 6401 hold (process used to detain an individual for mental health examination). Further review showed the patient successfully eloped from the ED on the 3rd attempt to leave. She was taken back to the ED by the police department but refused to go back inside the ED. Patient #1 was placed on a 6404 hold (also known as Certificate of Need [CON], a legal document used in the involuntary commitment of patients where inpatient psychiatric treatment is necessary). Continued review showed "...pt will be taken to jail to wait, she will not come back inside ED..." Patient #1 was discharged to jail with diagnoses including Psychotic Disorder with Delusions due to known Physiological Condition, Auditory Hallucinations, and Visual Hallucinations.

Medical record review showed Patient #1 did not have a Mobile Crisis evaluation during the ED encounter on 12/13/2021.

Review of an EMS Prehospital Care Report showed EMS was dispatched to the county jail on 12/15/2021 at 10:55 AM for an unconscious/unresponsive patient (Patient #1). The nurse on scene "...STATED SHE THOUGHT SHE [Patient #1] HAD A SEIZURE AND THAT SHE WAS PROBABLY DETOXING. NURSE STATED SHE KNEW PATIENT HAD TESTED POSITIVE FOR BENZODIAZAPINES..." Patient #1 was uncooperative with the nurse, staff at the jail, and EMS personnel. The nurse on scene reported the patient's heart rate was 90 and her oxygen saturation was 81% (normal 95% or higher). Upon arrival EMS found Patient #1 lying on the floor awake, alert, and oriented to person. Patient #1 would not answer questions and did not appear "...TO BE IN A POSTICTAL STATE [period begins when a seizure subsides and ends when the patient returns to baseline. It typically lasts between 5 and 30 minutes and is characterized by disorienting symptoms such as confusion, drowsiness, hypertension, headache, nausea]...PATIENT WAS COMBATIVE THE ENTIRE EVENT...SHERRIFS DEPT [department] SENT AN CO [correction officer] TO RIDE ALONG WITH PATIENT AND EMS..." Patient #1 was placed on oxygen via nasal cannula at 3 lpm (liters per minute) with oxygen saturations improved. Continued review showed Patient #1 removed the nasal cannula and blood pressure cuff multiple times.

Medical record review of ED nurses notes showed Patient #1 presented to the ED by EMS on 12/15/2021 at 11:15 AM (47 hours 18 minutes after discharge to jail on 12/13/2021) with complaint of possible seizure and altered mental status. Upon arrival, Patient #1's blood pressure was 131/82, pulse 95, and oxygen saturation was 96% while receiving oxygen at 2 lpm by nasal cannula. Patient #1 was triaged as a level 4 on the ESI system indicating semi-urgent but not emergent needs. Continued review showed the patient was uncooperative, combative, and complained of stomach and lower back pain which was described as "...numb..." The patient was noted to be "...agitated, confused, grimacing..." Patient #1 was discharged with the police department on 12/15/2021 at 12:47 PM (1 hour 32 minutes after arrival).

Medical record review of laboratory results dated 12/15/2021 at 11:52 AM showed Patient #1's urine drug screen was negative for benzodiazepines.

Medical record review of ED Physician documentation showed Patient #1 was evaluated by a QMP on 12/15/2021 at 11:15 AM. The patient presented to the ED with decreased responsiveness. Patient #1's symptoms improved while in the ED and the patient was more alert. Continued review showed "...Patient was seen here in ED for hallucinations and acute psychosis 2 days ago - she was agitated and was given a 6-404 and sent to jail for psych hold: today she was going to breakfast and had an unwitnessed fall at the jail; staff found her unresponsive on the floor, still breathing, no seizure activity..." Patient #1's exam showed "...appears in no acute distress, alert, awake, but patient will not answer questions, will growl occasionally; kicking at staff and pulling off EKG [electrocardiogram-measures electrical activity of the heart] leads and BP [blood pressure] cuffs..." Further review showed a Computerized Tomography (CT-detailed x-ray) of Patient #1's head was performed and showed no abnormalities. Continued review showed mobile crisis had requested Patient #1's medical records for the patient's ED visit on 12/13/2021 to get placement for Patient #1 at a psychiatric facility. Patient #1 was released to jail to await placement at a psychiatric facility. Patient #1's diagnosis was Acute (severe and sudden onset) Psychosis. There was no documentation to indicate Patient #1's UDS performed on 12/13/2021 had been reviewed by the physician during this visit on 12/15/2021.

Medical record review showed an EKG was not performed for Patient #1 during the 11:15 AM ED encounter on 12/15/2021.

Review of an EMS Prehospital Care Report showed EMS was dispatched to the county jail on 12/15/2021 at 6:02 PM for a patient (Patient #1) with a low blood pressure and decreased oxygen saturation. Upon EMS arrival, Patient #1 was found lying slightly on her left side and appeared to be having a seizure. The Corrections Officer reported the patient had been to the ED earlier in the day for possible seizure, where she was treated and discharged back to the jail. Continued review showed Patient #1's seizure stopped when she was lifted from the floor and onto the stretcher. The patient was placed in the back of the ambulance where her vital signs were as follows: blood pressure was 132/76, heart rate was 132 and oxygen saturation was 72%. Patient #1 was placed on oxygen by a non-rebreather mask (device to provide additional oxygen) at 15 lpm. Further review showed Patient #1 had another seizure which stopped after 1 mg of Ativan (medication for seizures) was administered to the patient intravenously (IV). Patient #1 started seizing again as she was being taken into the ED.

Medical record review of ED nurses notes showed Patient #1 presented to the ED by EMS on 12/15/2021 at 6:32 PM (5 hours 45 minutes after discharge from the ED) with active seizures. Patient #1's airway was compromised with decreased respiratory effort. The patient was cyanotic (bluish discoloration) and sweaty. Patient #1 was triaged as a level 2 on the ESI system indicating emergent care was needed.

Medical record review of ED Physician documentation showed Patient #1 presented to the ED on 12/15/2021 after having a "...single isolated seizure, in status epilepticus [a seizure that lasts longer than 5 minutes or having more than 1 seizure within a 5-minute period, without returning to a normal level of consciousness between episodes]...the patient experienced loss of consciousness...Current symptoms: seizing. Patient was here earlier this morning for AMS [altered mental status] and sent back to jail to await [named psychiatric facility] transfer...The patient appears active grand mal seizures [loss of consciousness and violent muscle contractions] continue in ED with gasping respirations after additional Versed [anxiety medicine] given..." Continued review showed Patient #1 was intubated (breathing tube placed) at 6:57 PM (25 minutes after arrival) by the ED physician. An intraosseous line [used to give IV fluids in an emergency] and central line [intravenous] were placed while in the ED. Continued review showed Patient #1 was admitted to the intensive care unit (ICU) for further treatment. Patient #1's diagnoses were documented as Other Seizures, Adverse Effect of Benzodiazepines, Acute Respiratory Failure with Hypoxia, and Non-ST Elevation Myocardial Infarction (heart attack).

Medical record review of Patient #1's admission history and physical dated 12/16/2021 showed the patient had been seen in the ED earlier that day for "...altered mental status most likely secondary to polysubstance abuse and was sent to jail to await [named psychiatric facility] transfer...In the emergency room, patient was then intubated for respiratory failure with status epilepticus. UDS [urine drug screen] was positive for benzodiazepines and THC. It is felt that the patient was withdrawing from benzodiazepines when she had her seizure...Chest x-ray...shows...either left-sided pneumonia versus pleural effusion..." Patient #1's admission diagnoses included Acute non-ST Elevation Myocardial Infarction, Acute Status Epilepticus, Acute Benzodiazepine Withdrawal, Acute Respiratory Failure, Acute Urinary Tract Infection, Acute Left-Sided Pleural Effusion versus Pneumonia, Bipolar Disease, and Polysubstance Abuse.

During a telephone interview on 2/2/2022 at 2:55 PM, the Sheriff stated Patient #1 was not under arrest, but was in custody for 6401/6404 detention at the jail. Continued review revealed the jail's nurse suspected Patient #1 was detoxing (drug or alcohol withdrawal) and sent the patient to the ED for evaluation and treatment on 12/15/2021.

During an interview on 2/2/2022 at 6:00 PM, in the ED, Physician #1 reviewed Patient #1's medical record for her 1st ED encounter on 12/15/2021 and confirmed Patient #1 arrived in the ED on 12/15/2021 at 11:15 AM for possible seizure. Physician #1 reported the patient had a complete seizure work-up including a Head CT scan and labs which were normal. A repeat UDS was performed which was negative for benzodiazepines. Physician #1 stated Patient #1's combative behavior continued throughout this ED visit. There was no documentation to show the patient had seizure activity while in the ED and the patient was not postictal. Physician #1 stated based on information received from EMS, the ED exam, patient not being postictal, and no seizure in the ED, it was felt the patient had not had a "...true seizure..." Her vital signs were normal, and the seizure workup was negative, so the patient was returned to the jail to await placement at a psychiatric facility. Physician #1 reviewed Patient #1's medical record for her 2nd ED encounter on 12/15/2021 and confirmed Patient #1 was actively seizing when she arrived in the ED. Physician #1 confirmed Patient #1 was intubated and was admitted to the ICU.

During an interview on 2/2/2022 at 5:30 PM, in the Chief Executive's Office (CEO), the CEO confirmed psychiatric patients were sometimes held in the jail pending placement in a psychiatric facility. This was done for the patient's safety, staff safety, and safety of other patients in the ED. He stated "...I know it's unorthodox, but we don't have a choice...we don't have a safe room..."

During a telephone interview on 2/8/2022 at 2:10 PM, Physician #1 stated Patient #1's initial ED workup on 12/15/2021 was negative and showed no indication the patient had a seizure. Physician #1 stated "...Retrospectively and presumably...because she had no history of seizures, no metabolic disorders, and no tumors were seen...she presumably had the seizure because of benzo [benzodiazepine] withdrawal..."

During a telephone interview on 2/14/2022 at 11:30 AM, Officer #1 stated Patient #1 was transported to the ED on 12/15/2021 after she became unresponsive and had "...white color to her skin..." Officer #1 reported Patient #1 looked at the staff but would not say anything or respond to them. The patient's oxygen saturation was in the 80's.

During a telephone interview on 2/14/2022 at 11:42 AM, Officer #2 stated Patient #1 had been standing at the cell door talking but not making sense prior to collapsing to the floor on the morning of 12/15/2021. Officer #2 stated she heard a noise and saw Patient #1 laying on the floor, pale and drooling. The patient was assessed by medical staff at the jail and was transported to the ED by ambulance. Officer #2 rode in the back of the ambulance to the ED and reported Patient #1 was awake and pulling all equipment off during the transport. Upon arrival to the ED, the patient remained awake but uncooperative. Continued interview revealed Officer #2 stayed at the hospital with the patient while tests were performed. Patient #1 was discharged to the jail with Officer #2. During the evening of 12/15/2021, Officer #2 noticed Patient #1's breathing had changed. Continued interview revealed Patient #1 was seizing, drooling, and was unresponsive. Officer #2 stated the patient's oxygen saturation was 77-80% and she could not get a blood pressure. EMS was called and Patient #1 was transported to the ED.

During a telephone interview on 2/14/2022 at 12:00 PM, the Quality Management Director stated Patient #1 did not receive a mobile crisis evaluation while in the ED on 12/13/2021.

During a telephone interview on 2/14/2022 at 12:50 PM, Physician #2 stated Patient #1 presented to the ED from the jail with altered mental status on 12/15/2021 (1st encounter on 12/15/2021). Continued interview revealed the patient was neurologically intact but refused to cooperate. Physician #2 stated she typically reviewed laboratory and test results from recent ED visits to determine what treatment needed to be provided. Physician #2 stated all she had documented in Patient #1's past history was what had transpired for the 6404 hold the patient had been placed on. Physician #2 was asked if Patient #1 could have been detoxing/withdrawing since her urine drug screen was positive for benzodiazepines on 12/13/2021 but negative on 12/15/2021. Physician #2 stated she had not considered withdrawal because the patient "...didn't have benzo's listed as a medication she was taking..." and the positive result for benzodiazepines had not been confirmed. Physician #2 stated Patient #1 was discharged to the jail versus holding at the hospital because the patient was a flight risk. Physician #2 agreed seizures were a potential side effect of benzodiazepine withdrawal.

During a telephone interview on 2/14/2022 at 2:15 PM, Paramedic #1 confirmed Patient #1 was transported to the ED for possible seizure and altered mental status the morning of 12/15/2021. Paramedic #1 stated the jail nurse reported she thought the patient had a seizure. Continued review revealed Patient #1 was not lethargic and had no loss of consciousness, was "...looking around at us..." and looked at him when spoken to. Paramedic #1 stated the patient provided her name but would not answer other questions, was combative, uncooperative, and would not leave the equipment on during transport.

During a telephone interview on 2/14/2022 at 2:25 PM, Physician #1 stated when Patient #1 first arrived on 12/13/2021, she kept wandering out of her room and heading toward the door. He stated she was "...clearly psych agitated..." and had experienced a "...psychotic break..." When asked who made the decision for the patient to go to the jail to await mobile crisis he replied "...she did...when she refused to come back in..." Physician #1 stated the patient refused further medication, refused to go back into the ED and stated she would rather go to jail. Physician #1 stated "...can't hog tie them and put them in a bed..." Continued review revealed it was law enforcement's decision to enforce a 6404. Physician #1 stated Patient #1 had been medically cleared and was awaiting mobile crisis evaluation when she refused to return to the ED.

The hospital failed to provide an ongoing medical screening examination for Patient #1's psychiatric condition while waiting for psychiatric facility inpatient services.

Based on review of facility policy, medical record review, review of Emergency Medical Services (EMS) Prehospital Care Records, and interviews, the facility failed to ensure stabilizing treatment was provided for 1 patient (Patient #1) who presented to the Emergency Department (ED) with Altered Mental Status, of 32 ED patients sampled.

The findings include:

Review of the facility's policy "EMTALA [Emergency Medical Treatment and Labor Act]-Medical Screening and Treatment of Emergency Medical Conditions" effective 6/2020 showed "...Emergency Medical Condition [EMC] means...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment of bodily functions; or Serious dysfunction of any bodily organ or part...To Stabilize means, with respect to an Emergency Medical Condition to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility...A patient is considered stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging a patient with psychiatric condition(s), the patient is considered to be stable for discharge when he/she is no longer considered to be a threat to him/her or to others. Also, a psychiatric patient is considered stable when they are protected and prevented from injuring or harming him/herself or others. The administration of chemical or physical restraints for purposes of transferring an individual from one facility to another may stabilize a psychiatric patient for a period of time and remove the immediate EMC but the underlying medical condition may persist and if not treated for longevity the patient may experience exacerbation of the EMC. Therefore, practitioners should use great care when determining if the medical condition is in fact stable after administering chemical or physical restraints..."

Medical record review of ED nurses notes showed Patient #1 presented to the ED as a 'walk-in" on 12/13/2021 at 8:55 AM and stated "...I'm a drug addict. I need help..." The patient was triaged as a level 3 (nonurgent) on the Emergency Severity Index (ESI) system (a 5-level system used to categorize ED patients). Continued review showed Patient #1 received Geodon (antipsychotic medication) 20 milligrams (mg) intramuscular (IM) at 9:19 AM, Potassium Chloride (electrolyte replacement) 40 milliequivalents (mEq) by mouth (PO) at 11:25 AM, and Rocephin (antibiotic) 1 gram IM at 10:53 AM. Patient #1 was discharged to police custody to "...hold at jail to wait for mobile crisis placement [to psychiatric facility]..." on 12/13/2021 at 11:33 AM (2 hours 38 minutes after arrival).

Medical record review of laboratory results dated 12/13/2021 at 9:45 AM showed Patient #1's urine drug screen (UDS - used to test for presence of drugs) was positive for THC (marijuana) and benzodiazepines (medication used to treat anxiety).

Medical record review of ED Physician documentation showed Patient #1 received a medical screening exam (MSE) by a qualified medical provider (QMP) on 12/13/2021 at 8:56 AM. The patient presented to the ED with "...psychosis [severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality], has experienced auditory hallucinations [perception of hearing something not present], has experienced visual hallucinations [perception of seeing something not present], a history of substance [drug] abuse, Polypharmacy [multiple drugs] per pt [patient]..." Patient #1's exam showed "...Behavior/mood is anxious, aggressive, delirious, Affect is animated, Oriented to person, place, time, Patient has no thoughts/intents to harm self or others. Judgement/Insight is impaired. Delusions/hallucinations are present and described as Visual, seeing deceased father in flowers on birdcage; Auditory, hearing deceased family members talking to her. NO COMMAND VOICES [voices instructing patient]..."

Medical record review of ED Physician Documentation dated 12/13/2021 at 11:24 AM showed Patient #1 attempted to leave the ED twice while she was on a 6401 hold (process used to detain an individual for mental health examination). Further review showed the patient successfully eloped from the ED on the 3rd attempt. She was taken back to the ED by the police department but refused to go back inside the ED. Patient #1 was placed on a 6404 hold (also known as certificate of need [CON], a legal document used in the involuntary commitment of patients where inpatient psychiatric treatment is necessary). Continued review showed "...pt will be taken to jail to wait, she will not come back inside ED..." Patient #1 was discharged to jail with diagnoses including Psychotic Disorder with Delusions due to known Physiological Condition, Auditory Hallucinations, and Visual Hallucinations.

Medical record review showed Patient #1 did not have a mobile crisis evaluation during the ED encounter on 12/13/2021.

Review of an EMS Prehospital Care Report showed EMS was dispatched to the county jail on 12/15/2021 at 10:55 AM for an unconscious/unresponsive patient (Patient #1). The nurse on scene "...STATED SHE THOUGHT SHE [Patient #1] HAD A SEIZURE AND THAT SHE WAS PROBABLY DETOXING. NURSE STATED SHE KNEW PATIENT HAD TESTED POSITIVE FOR BENZODIAZAPINES..." Patient #1 was uncooperative with the nurse, staff at the jail, and EMS personnel. The nurse on scene reported the patient's heart rate was 90 and her oxygen saturation was 81% (normal 95% or higher). Upon arrival EMS found Patient #1 lying on the floor awake, alert, and oriented to person. Patient #1 would not answer questions and did not appear "...TO BE IN A POSTICTAL STATE [period begins when a seizure subsides and ends when the patient returns to baseline. It typically lasts between 5 and 30 minutes and is characterized by disorienting symptoms such as confusion, drowsiness, hypertension, headache, nausea]...PATIENT WAS COMBATIVE THE ENTIRE EVENT...SHERRIFS DEPT [department] SENT AN CO [correction officer] TO RIDE ALONG WITH PATIENT AND EMS..." Patient #1 was placed on oxygen via nasal cannula at 3 lpm (liters per minute) with oxygen saturations improved. Continued review showed Patient #1 removed the nasal cannula and blood pressure cuff multiple times.

Medical record review of ED nurses notes showed Patient #1 presented to the ED by EMS on 12/15/2021 at 11:15 AM (47 hours 18 minutes after discharge to jail on 12/13/2021) with complaint of possible seizure and altered mental status. Upon arrival, Patient #1's blood pressure was 131/82, pulse 95, and oxygen saturation was 96% while receiving oxygen at 2 lpm by nasal cannula. Patient #1 was triaged as a level 4 on the ESI system indicating semi-urgent but not emergent needs. Continued review showed the patient was uncooperative, combative, and complained of stomach and lower back pain which was described as "...numb..." The patient was noted to be "...agitated, confused, grimacing..." Patient #1 was discharged with the police department on 12/15/2021 at 12:47 PM (1 hour 32 minutes after arrival).

Medical record review of laboratory results dated 12/15/2021 at 11:52 AM showed Patient #1's urine drug screen was negative for benzodiazepines.

Medical record review of ED Physician documentation showed Patient #1 received a MSE by a QMP on 12/15/2021 at 11:15 AM. The patient presented to the ED with decreased responsiveness. Patient #1's symptoms improved while in the ED and the patient was more alert. Continued review showed "...Patient was seen here in ED for hallucinations and acute psychosis 2 days ago - she was agitated and was given a 6-404 and sent to jail for psych hold: today she was going to breakfast and had an unwitnessed fall at the jail; staff found her unresponsive on the floor, still breathing, no seizure activity..." Patient #1's exam showed "...appears in no acute distress, alert, awake, but patient will not answer questions, will growl occasionally; kicking at staff and pulling off EKG [measures electrical activity of the heart] leads and BP [blood pressure] cuffs..." Continued review showed mobile crisis had requested Patient #1's medical records for the patients ED visit on 12/13/2021 in order to get placement for Patient #1 at a psychiatric facility. Patient #1 was released to jail to await placement at a psychiatric facility. Patient #1's diagnosis was Acute (severe and sudden onset) Psychosis. There was no documentation to indicate Patient #1's UDS performed on 12/13/2021 had been reviewed by the physician during this visit on 12/15/2021.

Medical record review showed an electrocardiogram (EKG-test to detect heart problems) was not performed for Patient #1 during the 11:15 AM ED encounter on 12/15/2021.

Review of an EMS Prehospital Care Report showed EMS was dispatched to the county jail on 12/15/2021 at 6:02 PM for a patient (Patient #1) with a low blood pressure and decreased oxygen saturation. Upon EMS arrival, Patient #1 was found lying slightly on her left side and appeared to be having a seizure. The Corrections Officers reported the patient had been to the ED earlier in the day for possible seizure, where she was treated and discharged back to the jail. Continued review showed Patient #1's seizure stopped when she was lifted from the floor and onto the stretcher. The patient was placed in the back of the ambulance where her vital signs were as follows: blood pressure was 132/76, heart rate was 132 and oxygen saturation was 72%. Patient #1 was placed on oxygen by a non-rebreather mask (device to provide additional oxygen) at 15 lpm. Further review showed Patient #1 had another seizure which stopped after 1 mg of Ativan (medication for seizures) was administered to the patient intravenously (IV). Patient #1 started seizing again as she was being taken into the ED.

Medical record review of ED nurses notes showed Patient #1 presented to the ED by EMS on 12/15/2021 at 6:32 PM (5 hours 45 minutes after discharge from the ED) with active seizures. Patient #1's airway was compromised with decreased respiratory effort. The patient was cyanotic (bluish discoloration) and sweaty. Patient #1 was triaged as a level 2 on the ESI system indicating emergent care was needed.

Medical record review of ED Physician documentation showed Patient #1 presented to the ED on 12/15/2021 after having a "...single isolated seizure, in status epilepticus [a seizure that lasts longer than 5 minutes or having more than 1 seizure within a 5-minute period, without returning to a normal level of consciousness between episodes]...the patient experienced loss of consciousness...Current symptoms: seizing. Patient was here earlier this morning for AMS [altered mental status] and sent back to jail to await [named psychiatric facility] transfer...The patient appears active grand mal seizures [loss of consciousness and violent muscle contractions] continue in ED with gasping respirations after additional Versed [anxiety medicine] given..." Continued review showed Patient #1 was intubated (breathing tube placed) at 6:57 PM (25 minutes after arrival) by the ED physician. An intraosseous line [used to give IV fluids in an emergency] and central line [intravenous] were placed while in the ED. Continued review showed Patient #1 was admitted to the intensive care unit (ICU) for further treatment. Patient #1's diagnoses were documented as Other Seizures, Adverse Effect of Benzodiazepines, Acute Respiratory Failure with Hypoxia, and Non-ST Elevation Myocardial Infarction (heart attack).

Medical record review of Patient #1's Cardiology Report showed Patient #1 had an EKG on 12/15/2021 at 10:33 PM which showed "...Sinus tachycardia [fast heart rate]...Nonspecific and diffuse ST-segment abnormality [may indicate cardiac injury] Should be correlated with clinical findings..."

Medical record review of Patient #1's admission history and physical dated 12/16/2021 showed the patient had been seen in the ED earlier that day for "...altered mental status most likely secondary to polysubstance abuse and was sent to jail to await [named psychiatric facility] transfer...In the emergency room, patient was then intubated for respiratory failure with status epilepticus. UDS [urine drug screen] was positive for benzodiazepines and THC. It is felt that the patient was withdrawing from benzodiazepines when she had her seizure...Chest x-ray...shows...either left-sided pneumonia versus pleural effusion..." Patient #1's admission diagnoses included Acute non-ST Elevation Myocardial Infarction, Acute Status Epilepticus, Acute Benzodiazepine Withdrawal, Acute Respiratory Failure, Acute Urinary Tract Infection, Acute Left-Sided Pleural Effusion versus Pneumonia, Bipolar Disease, and Polysubstance Abuse.

During a telephone interview on 2/2/2022 at 2:55 PM, the Sheriff stated Patient #1 was not under arrest, but was in custody for 6401/6404 detention at the jail. Continued review revealed the jail's nurse suspected Patient #1 was detoxing (drug or alcohol withdrawal) and sent the patient to the ED for evaluation and treatment on 12/15/2021.

During an interview on 2/2/2022 at 6:00 PM, in the ED, Physician #1 reviewed Patient #1's medical record for her 1st ED encounter on 12/15/2021 and confirmed Patient #1 arrived in the ED on 12/15/2021 at 11:15 AM for possible seizure. Physician #1 reported the patient had a complete seizure work-up including a Head CT scan and labs which were normal. A repeat UDS was performed which was negative for benzodiazepines. Physician #1 stated Patient #1's combative behavior continued throughout this ED visit. There was no documentation to show the patient had seizure activity while in the ED and the patient was not postictal. Physician #1 stated based on information received from EMS, the ED exam, patient not being postictal, and no seizure in the ED, it was felt the patient had not had a "...true seizure..." Her vital signs were normal, and the seizure workup was negative, so the patient was returned to the jail to await placement at a psychiatric facility. Physician #1 reviewed Patient #1's medical record for her 2nd ED encounter on 12/15/2021 and confirmed Patient #1 was actively seizing when she arrived in the ED. Physician #1 confirmed Patient #1 was intubated and was admitted to the ICU.

During an interview on 2/2/2022 at 5:30 PM, in the Chief Executive's Office (CEO), the CEO confirmed psychiatric patients were sometimes held in the jail pending placement in a psychiatric facility. This was done for the patient's safety, staff safety, and safety of other patients in the ED. He stated "...I know it's unorthodox, but we don't have a choice...we don't have a safe room..."

During a telephone interview on 2/2/2022 at 6:25 PM, Physician #2 confirmed Patient #1 returned a second time to the ED on 12/15/2021 with active seizures and required intubation.

During a telephone interview on 2/8/2022 at 2:10 PM, Physician #1 stated Patient #1's initial ED workup on 12/15/2021 was negative and showed no indication the patient had a seizure. Physician #1 stated "...Retrospectively and presumably...because she had no history of seizures, no metabolic disorders, and no tumors were seen...she presumably had the seizure because of benzo [benzodiazepine] withdrawal..."

During a telephone interview on 2/14/2022 at 11:30 AM, Officer #1 stated Patient #1 was transported to the ED on 12/15/2021 after she became unresponsive and had "...white color to her skin..." Officer #1 reported Patient #1 looked at the staff but would not say anything or respond to them. The patient's oxygen saturation was in the 80's.

During a telephone interview on 2/14/2022 at 11:42 AM, Officer #2 stated Patient #1 had been standing at the cell door talking but not making sense prior to collapsing to the floor on the morning of 12/15/2021. Officer #2 stated she heard a noise and saw Patient #1 laying on the floor, pale and drooling. The patient was assessed by medical staff at the jail and was transported to the ED by ambulance. Officer #2 rode in the back of the ambulance to the ED and reported Patient #1 was awake and pulling all equipment off during the transport. Upon arrival to the ED, the patient remained awake but uncooperative. Continued interview revealed Officer #2 stayed at the hospital with the patient while tests were performed. Patient #1 was discharged to the jail with Officer #2. During the evening of 12/15/2021, Officer #2 noticed Patient #1's breathing had changed. Continued interview revealed Patient #1 was seizing, drooling, and was unresponsive. Officer #2 stated the patient's oxygen saturation was 77-80% and she could not get a blood pressure. EMS was called and Patient #1 was transported to the ED.

During a telephone interview on 2/14/2022 at 12:50 PM, Physician #2 stated Patient #1 presented to the ED from the jail with altered mental status on 12/15/2021 (1st encounter on 12/15/2021). Continued interview revealed the patient was neurologically intact but refused to cooperate. Physician #2 stated she typically reviewed laboratory and test results from recent ED visits to determine what treatment needed to be provided. Physician #2 stated all she had documented in Patient #1's past history was what had transpired for the 6404 hold the patient had been placed on. Physician #2 was asked if Patient #1 could have been detoxing/withdrawing since her urine drug screen was positive for benzodiazepines on 12/13/2021 but negative on 12/15/2021. Physician #2 stated she had not considered withdrawal because the patient "...didn't have benzo's listed as a medication she was taking..." and the positive result for benzodiazepines had not been confirmed. Physician #2 stated Patient #1 was discharged to the jail versus holding at the hospital because the patient was a flight risk. Physician #2 agreed seizures were a potential side effect of benzodiazepine withdrawal.

During a telephone interview on 2/14/2022 at 2:15 PM, Paramedic #1 confirmed Patient #1 was transported to the ED for possible seizure and altered mental status the morning of 12/15/2021. Paramedic #1 stated the jail nurse reported she thought the patient had a seizure. Continued review revealed Patient #1 was not lethargic and had no loss of consciousness, was "...looking around at us..." and looked at him when spoken to. Paramedic #1 stated the patient provided her name but would not answer other questions, was combative, uncooperative, and wouldn't leave the equipment on during transport.

During a telephone interview on 2/14/2022 at 2:25 PM, Physician #1 stated when Patient #1 first arrived on 12/13/2021, she kept wandering out of her room and heading toward the door. He stated she was "...clearly psych agitated..." and had experienced a "...psychotic break..." When asked who made the decision for the patient to go to the jail to await mobile crisis he replied "...she did...when she refused to come back in..." Physician #1 stated the patient refused further medication, refused to go back into the ED and stated she would rather go to jail. Physician #1 stated "...can't hog tie them and put them in a bed..." Continued review revealed it was law enforcement's decision to enforce a 6404. Physician #1 stated Patient #1 had been medically cleared and was awaiting mobile crisis evaluation when she refused to return to the ED.

Patient #1 did not have her emergency medical condition stabilized prior to being sent to jail to wait for inpatient psychiatric placement.