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Based on interview, record review, policy review and video surveillance, the hospital failed to provide a medical screening examination (MSE) within the hospital's capability and capacity, to ensure that an emergency medical condition (EMC) did not exist for one patient (#21). The patient presented to the hospital's Emergency Department (ED) by local law enforcement, with an affidavit (a written statement confirmed by oath, for use as evidence in court) for an Involuntary Hold (96 Hour Hold, court-ordered evaluation by behavioral specialists to determine if a person is at risk of harm to self or others), for suicidal ideations (SI, thoughts of causing ones own death). The patient returned to the ED a second time with law enforcement and the hospital failed to perform a medical screening examination and instead directed law enforcement to transport the patient to Hospital B prior obtaining acceptance, or determining whether the medical benefits of transport by law enforcement exceeded the medical risks. The hospital's ED saw an average of 506 patients per month and had an average of 17 transfers per month over the previous six months.



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Based on interview, record review, policy review, and video surveillance review, the hospital failed to provide a medical screening examination (MSE) within its capacity and capability, to determine if an emergency medical condition (EMC) existed for one patient (#21) of 30 patients' records reviewed who presented to the Emergency Department (ED) for emergency care, out of a sample selected from 04/19/20 to 10/19/20. Patient #21 presented to the ED by law enforcement for suicidal ideations (SI, thoughts of causing ones own death) with an affidavit (a written statement confirmed by oath, for use as evidence in court) for an involuntary hold (96 Hour Hold, court-ordered evaluation by behavioral specialists to determine if a person is at risk of harm to self or others). The hospital's ED saw an average of 506 patients per month and had an average of 17 transfers per month over the previous six months.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," revised 01/2019, showed that:

- Any individual who presents to the ED will be provided with a MSE to determine whether that individual is experiencing an EMC.
- 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 serious jeopardy in the health of the individual.
- The medical examination shall include those ancillary services routinely available to the ED.

Review of the law enforcement document titled, "Inclusive Case Report," dated 10/20/20, showed that:
- On 09/06/20 at 4:20 AM, Law Enforcement Sergeant FF, and Law Enforcement Officer GG, were dispatched to the home of Patient #21.
- The patient's family told the officers that Patient #21 had left the residence, that he talked about killing himself, and that he was extremely intoxicated.
- When the officers located the patient, he told the officers that he needed to go to jail because he was going to hurt himself or someone else.
- He told the officers he had been drinking and felt sick.
- While in the back of the patrol car he stated he was going to kill himself.
- Law Enforcement Officer GG completed an affidavit for a 96-hour hold and transported him to the hospital.
- Hospital staff called law enforcement approximately one hour after Patient #21's arrival, due to the patient's behavior and verbal aggression.
- Before the officers arrived at the hospital, the patient had left.
- Patient #21 was located across the street from the hospital.
- Upon Patient #21's return to the hospital, nursing staff advised the officers that they would not accept the patient and that the officers were to transport the patient to Hospital B (nearby hospital).
- The patient was transported to Hospital B and released into the care of the staff.

During a telephone interview on 10/29/20 at 12:21 PM, Law Enforcement Sergeant FF, stated that Patient #21's family called law enforcement due to his suicidal statements and property damage. By the time law enforcement arrived to the residence, the patient had left the home, and was found by officers hiding in bushes. The patient informed the officers that he needed to be put in handcuffs before he hurt himself or someone else, so the patient was handcuffed and transported to the hospital by law enforcement.

During a telephone interview on 10/30/20 at 9:40 AM, Law Enforcement Officer GG stated that she when she found Patient #21 hiding in the bushes, he admitted that he had used drugs and drank alcohol, and that he wanted to hurt himself.

Review of the local law enforcement document titled, "Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 09/06/20 and signed by Law Enforcement Officer GG showed:
- Patient #21 stated multiple times that he wanted to hurt himself or others.
- He asked Law Enforcement Officer GG to place him in handcuffs so he didn't hurt anyone.
- In the back of the patrol car the patient stated he was "going to kill himself."

Review of Patient #21's ED record dated 09/06/20, showed that Patient #21 was a 19-year-old male who presented by law enforcement to the ED at 4:45 AM, for a 96-hour hold. The patient's chief complaint showed that a law enforcement provided affidavit, documented that prior to the patient's arrival, the patient requested to be handcuffed because he was going to hurt someone or kill himself. The patient told ED staff that he had been drinking excessively that day, and was afraid he was going to hurt himself or someone else. In addition to alcohol, the patient verbalized cannabis (psychoactive drug for recreational purposes) and cocaine (a strong stimulant drug used as a recreational drug) use. His alcohol level was 144 (greater than what is considered "toxic") and his drug screen resulted positive for cannabis. The patient was identified as an imminent risk of suicide after he verbalized that over the past few weeks, he wished he was dead and felt others would be better off if he was, explained his history of suicide attempts with inpatient psychiatric care, and admitted to active thoughts of suicide. Staff EE, RN, documented that while in the ED, the patient paced, was talkative and tearful, avoided eye contact, rambled, and had recurring thoughts which included guilt and worthlessness. At 6:06 AM, Staff O, ED Physician, documented that when he went to examine the patient, the patient talked non-sensical, became animated and agitated, and believed the physician was a law enforcement officer. The patient became belligerent and began to shout, threatened physical harm to the physician, and told him to get the "F" out of the room. The patient then exited the hospital while staff were in the process of contacting law enforcement, returned to speak with law enforcement, began banging on the phone, and left again, slamming the door and shouting on the way out. Staff O documented that the patient left against medical advice (AMA) prior to a completed examination, in a state of agitation. He was found by police, and after discussion with the administrator on call (AOC), the hospital staff recommended that law enforcement take him to Hospital B "where security is available" for further evaluation "if they (law enforcement) felt he was a potential harm to himself."

Review of the hospital's video surveillance of Patient #21 (no audio) dated 09/06/20 showed that at:
- 4:48 AM, the patient walked into the ED room, faced the wall, and rocked back and forth on his feet.
- 5:57 AM, Staff O, ED Physician, entered the room, touched the patient's shoulder and then shook his shoulder to wake him.
- 5:59 AM, Staff O shook the patient's shoulder again.
- 6:00 AM, the patient became agitated and looked down at his wrist several times, as if he were checking the time, although he was not wearing a watch.
- 6:02 AM, the patient appeared to yell at Staff O, and Staff O exited the room.
- 6:03 AM, while nursing staff and Staff O sat in the nurses' station, the patient walked out of the ED examination room, appeared to yell and clap his hands, then exited the ED.
- 6:04 AM, the patient then exited the hospital.
- 6:05 AM, the patient returned to the ED waiting room registration window, and appeared to speak to a (non-visualized) staff member. He appeared angry and pointed at staff and then began slapping a telephone through the registration window.
- 6:06 AM, the patient left the hospital for the second time and punched the glass doors as he exited.

During a telephone interview on 10/27/20 at 1:00 PM, Staff BB, RN, ED Director, stated that Patient #21 did not leave AMA (as documented), and that she was "shocked" no one attempted to de-escalate or restrain (any method used to reduce the ability of a patient to move freely) the patient when he eloped.

Review of the hospital's policy titled, "Suicide Precautions and/or Psychiatric/Behavioral Disorders - Involuntary Hold" revised 01/2019, showed:
- Although an involuntary hold cannot be carried out at the hospital, the documentation to support a hold can be initiated when the patient presents to the ED.
- The ED physician may initiate a consult with nearby mental health assessment staff, or contact the attending physician for transfer to an inpatient psychiatric unit, when appropriate.
- If a patient has not been cleared by nearby mental health assessment staff and wants to leave or attempts to elope, staff should notify law enforcement.
- If a patient tries to elope, staff should use best efforts to keep the patient in the hospital.
- If a patient attempts to elope while under one-to-one observation, staff should call a Code Green (an emergency situation where a patient has become aggressive, and staff quickly respond in an attempt to manage the patient) as a show of force, attempt verbal redirection, and attempt to restrain.

During a telephone interview on 10/20/20 at 9:30 AM, Staff Q, ED RN, stated that when Patient #21 was brought in, she placed him in a psychiatric safe room (a room that has been cleared of any objects a patient might use to harm themselves or others) and on one-to-one observation. Staff Q added that she was fearful for everyone's safety when the patient became angry and screamed at Staff O, and that although it was not a normal occurrence for an ED physician to send a patient away without a MSE, law enforcement was the only way they could get help to assist with an angry, "psychotic patient."

During a telephone interview on 11/17/20 at 10:00 AM, Staff EE, RN, stated that Patient #21 was fidgety, threatened to punch the physician in the face, and when staff contacted law enforcement, the patient left. Staff EE added that even though the patient acted violent and unstable, she did not attempt to de-escalate him and that "If the doors could have locked, we would have locked them and kept the patient outside the building."

During a telephone interview on 10/20/20 at 3:00 PM, Staff DD, RN, House Supervisor, stated that she could have called for staff assistance with the patient, but there were not enough staff in the hospital to respond.

Review of a hospital document titled, "Letter of Agreement," (between a mental health service agency and the hospital) dated 04/08/97, showed that mental health services would be offered for assessment, referral, and/or treatment for area residents who presented with a mental health problem, and that clients who required locked facilities would be referred to other hospitals.

During a telephone interview on 11/17/20 at 10:00 AM, Staff EE, RN confirmed that ED staff have 24-hours a day telephone access to nearby mental health assessment staff, for psychiatric evaluation of patients.

Review of the mental health on-call calendar, available to the hospital's ED staff, showed mental health assessment staff were on-call for 09/06/20.

The hospital failed to contact the mental health services for a mental health assessment, as part of an MSE for Patient #21.

During a telephone interview on 10/20/20 at 10:00 AM and again on 11/24/20 at 10:30 AM, Staff O, ED Physician, stated that he was aware Patient #21 was brought to the ED by law enforcement with an affidavit for a 96-hour hold. Staff O was also aware that the patient had threatened harm to himself and others, and although he knew he should have kept the patient from leaving, he would not confront a patient if they were aggressive, or had threatened him or staff. Staff O admitted that he previously had psychiatric patients elope who were brought in for a 96 hour hold, and staff would contact law enforcement had have them returned to the ED. When law enforcement staff returned Patient #21, the officers said they could not stay to assist with the patient, so the physician informed them he could not examine the patient law enforcement was direct them to take the patient to Hospital B. Staff O believed the hospital's liability had ended when the patient eloped.

Review of the hospital's video surveillance dated 09/06/20, showed that after Patient #21 eloped, four law enforcement vehicles arrived at the hospital ambulance bay at 6:18 AM. One officer exits his vehicle and enters the hospital. At 6:30 AM, an officer appears to speak to someone sitting in the back of one of the law enforcement vehicles, and by 6:31 AM, all four law enforcement vehicles have left the hospital.

Review of an email from Staff EE, RN, to Staff H, Quality and Risk Director, dated 09/08/20, showed that Staff EE, RN, documented that Patient #21 was "clearly" mentally unstable, and that when the patient was returned by law enforcement officers, he was left in the patrol car parked in the ambulance bay, and she could hear the patient scream and hit his head against the windows of the law enforcement car.

During a telephone interview on 10/20/20 at 3:00 PM, Staff DD, RN, House Supervisor, stated that when the officers could not stay to assist, she called the AOC and it was decided to send the patient to Hospital B.

During an interview on 10/20/20 at 3:15 PM, Staff R, Human Resources Director, stated that she was the AOC on 09/06/20, and authorized the transport of Patient #21 to Hospital B.

During a telephone interview on 10/30/20 at 9:40 AM, Law Enforcement Officer GG, stated that officers were available to help hospital staff get patients to a bed and restrained, if necessary.

During a telephone interview on 10/29/20 at 12:21 PM, Law Enforcement Sergeant FF, stated that no one asked him to stay at the hospital and assist with the patient or he would have, and that he was the officer who transported Patient #21 to Hospital B, where the patient was immediately restrained and given medication.

During a telephone interview on 10/21/20 at 2:51 PM, Staff CC, ED Medical Director, stated that he expected staff to attempt to stop Patient #21 from eloping, and added that a MSE should be completed on all patients.

During a telephone interview on 10/21/20 at 4:00 PM, Staff F, Chief Executive Officer (CEO), stated that the nursing staff and ED Physician did not follow the EMTALA guidelines or policy.

The hospital failed to provide Patient #21 with a MSE to determine if he was suffering from an EMC. The patient presented by law enforcement with an affidavit for a 96-hour hold, after he had threatened harm to himself and others, and was "going to kill himself." The hospital had the capability to contact on-call mental health assessment staff, who were available by phone for evaluation of the patient's mental health, and referral for inpatient placement, if necessary. The patient escalated and eloped, and hospital staff made no attempts to prevent him from leaving. After the patient was returned to the ED by law enforcement, instead of completing the MSE, the hospital directed law enforcement to transport the patient to Hospital B.

Review of Patient #21's ED record from Hospital B, dated 09/06/20, showed that when law enforcement brought the patient to Hospital B, he screamed at staff, was very uncooperative, and attempted to flee. He was placed in restraints and given medication to calm him. He was provided with a MSE, and diagnosed with bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), polysubstnace abuse (use of multiple drugs) and SI, and transferred to Hospital C (psychiatric hospital within Hospital B) for inpatient psychiatric care.

Review of Patient #21's medical record from Hospital C, dated 09/07/20, showed that he was admitted involuntarily because of SI, with an admission diagnosis of major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), Tetrahydrocannabinol (marijuana, psychoactive drug from the cannabis plant used primarily for medical or recreational purposes) use, and alcohol use. Recommendations for his treatment included keeping the patient safe and stabilization of his depression.

Based on interview, record review, policy review and video surveillance review, the facility failed to ensure an appropriate transfer for one suicidal (thoughts of causing ones own death) patient (#21), of 30 random patient records reviewed between 04/19/20 to 10/19/20, who presented to the Emergency Department (ED) for care. After the patient eloped from the ED and was returned by law enforcement, the hospital refused the patient and requested law enforcement officers transfer the patient to Hospital B (nearby hospital with a dedicated ED) without notifying the hospital and ensuring the hospital had the ability to accept the patient. The ED saw an average of 506 patients per month and had average of 17 transfers per month, over the last six months.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," revised 01/2019, showed that the ED physician, or designated hospital employee, shall obtain consent of the receiving hospital before the transfer of an individual, make arrangements for the patient transfer with the receiving hospital, document the individuals condition and stabilizing treatment in the medical record, and provide appropriate medical records of the individuals treatment, tests, diagnosis, transfer consent and certification to the receiving facility.

Review of Patient #21's ED record, showed that he was a 19-year-old male who was brought to the hospital by law enforcement on 09/06/20 at 4:45 AM, for a 96 hour hold. At 5:15 AM documentation showed the patient's heart rate was abnormally elevated at 130 beats per minute (an elevated heart rate can be associated with anxiety or agitation, or in cooperative patients it can be associated with physical disorders such as dehydration, heart problems or problems associated with ingestion of drugs of abuse). Further documentation in the medical record showed the patient was initially cooperative upon arrival and verbalized he wanted to kill himself, or hurt others. He was identified by a suicide screening (evaluation used to determine the potential risk for a person's desire to kill themselves) as an imminent risk of suicide, and responded that he had current thoughts of killing himself. He admitted to, and tested positive for, the use of drugs and alcohol. His blood alcohol level was 144 (greater than toxic), and he was anxious and rambled. ED Physician O documented that the patient spoke nonsensically (having no meaning, making no sense), became animated and agitated, and believed the physician was a law enforcement officer. The patient shouted and threatened the physician, and left before the history and examination was completed. The patient was documented by the physician to have left against medical advice (patient not advised of the risks of leaving indicated the patient eloped), was later found by police, and after discussion with the administrator on-call (AOC), was taken to Hospital B for further evaluation by law enforcement, "if they felt he was a potential harm to himself."

Review of the hospital's video surveillance dated 09/06/20, showed that after Patient #21 eloped from the ED, four law enforcement vehicles arrived at the hospital ambulance bay at 6:18 AM. One officer exited his vehicle and entered the hospital. At 6:30 AM, an officer appeared to speak to someone sitting in the back of one of the law enforcement vehicle, and by 6:31 AM, all four law enforcement vehicles left the hospital.

Review of an email from Staff EE, RN, to Staff H, Quality and Risk Director, dated 09/08/20, showed that Staff EE, RN, documented that Patient #21 was "clearly" mentally unstable, and that when the patient was returned by law enforcement officers, he was left in the patrol car parked in the ambulance bay, and she could hear the patient scream and hit his head against the windows of the law enforcement car.

During a telephone interview on 10/29/20 at 12:21 PM, Law Enforcement Sergeant FF, stated that when he returned Patient #21 to the ED, the physician informed him that he could not examine the patient, the staff refused to see the patient, and directed him to take the patient to Hospital B.

Prior to directing law enforcement to transport patient # 21 to Hospital B, the ED staff did not determine whether transport via police car was appropriate given the patient's abnormal vital signs were not addressed prior to his elopement. Upon return to the ED, the patient's level of agitation had increased to the point that he was actively engaging in self harm and his risk for deterioration had further increased. Transport by law enforcement to Hospital B instead of by ambulance with a paramedic in attendance, placed the patient at significant risk if his vital signs had continued to deteriorate, requiring medications or other advanced therapies like airway management and/or CPR.

During an interview on 10/20/20 at 4:55 PM, Staff G, Chief Nursing Officer (CNO), stated that she expected that every patient who presented to the ED for care, and required a higher level of care, would be appropriately transferred to an accepting hospital and that the transfer should be arranged by the transferring hospital.

During an interview on 10/27/20 at 9:39 AM, Staff BB, ED Director, stated that she expected any patient who needed to be transferred, would be transported to an accepting hospital by ambulance.

During a telephone interview on 10/30/20 at 9:40 AM, Law Enforcement Officer GG, stated that officers were available to help hospital staff get patients to a bed and restrained, if necessary.

During a telephone interview on 10/29/20 at 12:21 PM, Law Enforcement Sergeant FF, stated that no one asked him to stay at the hospital and assist with the patient or he would have, and that he was the officer who transported Patient #21 to Hospital B, where the patient was immediately restrained and given medication.

There was no indication in the medical record that Hospital B was notified of the patient's transfer to their facility, or that the facility had accepted the patient.

During an interview on 10/20/20 at 10:00 AM, Staff O, ED Physician, stated that when the patient left the ED, he was angry and a danger to others. When law enforcement returned the patient, he informed them he could not examine the patient, and directed them to take the patient to Hospital B. Staff O added that the hospital's liability ended when the patient eloped from the ED, and therefore, was not a transfer.

During an interview on 10/20/20 at 3:15 PM, Staff R, Human Resources Director, stated that she was the AOC on 09/06/20, and authorized Patient #21's transfer to Hospital B.

During a telephone interview on 10/21/20 at 2:51 PM, Staff CC, ED Medical Director, stated that he was made aware of the incident regarding Patient #21 on 09/06/20, and expected all patients to be transferred appropriately.

During a telephone interview on 10/21/20 at 4:00 PM, Staff F, CEO, stated that the nursing staff and ED physician did not follow EMTALA guidelines or policy.

Review of Hospital B's ED record dated 09/06/20, showed that the patient arrived by law enforcement on 09/06/20 at 6:45 AM. The patient was uncooperative, attempted to elope, was placed in restraints and medication was administered to calm him. He was diagnosed with bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), polysubstnace abuse (use of multiple drugs) and suicidal ideation (SI, thoughts of causing one's own death), and transferred to Hospital C (psychiatric hospital within Hospital B) for inpatient psychiatric care.





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