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Based on a review of 23 closed and 5 open medical records, including 2 psychiatric patient records, and interviews with hospital staff, it was determined the hospital failed to conduct complete screening exams on 3 of 23 patients reviewed, patient's #4, #12 and #23.


Patient #4 (Pt# 4) was transported to the Emergency Department (ED) by law enforcement from Pt# 4's place of work at approximately 2210 in late August on an Emergency Petition (EP) basis due to Pt# 4 cutting self on thighs and stating "[Pt# 4] has nothing to live for" and "threats of killing self", as witnessed by co-workers.


In the ED, Pt# 4 was appropriately triaged and a medical screening exam was completed by the ED physician at 2313. However, no evidence was found in the medical record the ED clinical staff conducted a psychiatric screening exam to rule out an emergency psychiatric condition based on Pt# 4's presenting symptoms and EP status. The patient was discharged home within 60 minutes. Based on documentation, the hospital failed to complete a psychiatric screening evaluation to determine if an emergency psychiatric condition existed.


Patient #12 was a young adult who presented to the ED alone as a walk-in in late September 2017 at 1938. Triage documentation stated in part, "Deliberate medication overdose, Encounter for psychological evaluation." Patient #12 had deliberately taken 6-7 tablets each an antipsychotic, an antidepressant, and an anti-tremor medication. Patient #12 was triaged as a level 2 due to a "Yes" answer to the question, "Is This a High Risk Situation Where The Patient is Confused/Lethargic/Disoriented or in Severe Pain/Distress?


Patient #12 was placed with a 1:1 staff for seizure and suicide precautions. An RN wrote in part, "Maryland Poison Control Center called at 2005. Recommends watching for anticholinergic (inclusive of increased heart rate) effects, seizure, prolonged QTC (cardiac function), hypotension (low blood pressure, and CNS (central nervous system) depression." The poison control center recommended performing EKGs every two hours for 24 hours and performing blood tests.


Nursing documented in part, "pt unsure if she was trying to commit (sic) suicide but states "I was just really stressed." Reasons for patient #12's stress were described as being bullied by the friend of a relative and experiencing stressors at home. The physician wrote in part, "Pt denies multiple times trying to hurt herself."


Patient #12's mother came to the hospital and was adamant that patient #12 not be evaluated at the hospital, and wanted patient to go to the outpatient mental health provider. The physician wrote in part, "The daughter does not decline discharge." Even though patient #12 was an adult and the hospital had a psychiatric unit with 24/7 psychiatric evaluation services in the ED, the hospital failed to conduct a psychiatric evaluation. Instead, the physician discharged patient #12 Against Medical Advice (AMA) to home.


Patient #23's first visit in June 2017, to the ED her chief complaint was "intermittent vaginal bleeding X 1 month." The patient was assessed including lab work, but no physical exam was conducted. Hg and Hct did not indicate any blood loss. Pt was discharged home with instructions to follow up with her PCP and gynecologist. Pt stated at the time she was unable to go to doctor due to lack of funds for a cab. Pt also has a history of behavioral health issues.


Patient #23's second visit was in July 2017. Patient #23 arrived by ambulance with complaint of abdominal pain. Patient stated she had left side flank pain and that her urine was green. An assessment was done including lab work. The blood work again did not indicate any loss of blood. Patient was directed to see her PCP and discharged home. Pt stated she did not have money for a cab to get to her doctor.


The patient's third visit was in September 2017. Pt. #23 arrived by ambulance with complaint of trouble breathing and stated she was manic and had been off her medication for 13 months. Pt had a seizure in the ED and was admitted overnight for observation. Assessment was completed including a CT of the head, an EEG and an analysis of urine. All tests were negative. Pt was discharged home with directions to follow up with her PCP and psychiatrist.


Patient #23's 4th visit was in November 2017. Pt arrived by ambulance with complaints of vaginal or rectal bleeding. She stated the bleeding first started in June and has been on and off since then. An assessment was completed on this visit including a physical gynecological exam. It was determined the patient had a labial mass, possibly cancerous, that was ulcerated and had evidence of a prolapsed uterus. Doctor informed patient that he suspected she has a cancerous mass.

In each of the emergency department visits for patient #23, a medical screening exam was performed but never assessed the patient's chief complaint The patient was instructed to follow up with her Primary Care Provider (PCP) and various medical specialists. Had an appropriate MSE (Medical Screening Exam) been completed on the patient's first visit, with a physical gynecological exam, her possible cancer could have been identified 4 months sooner. This time lapse may have allowed allow a much more serious outcome to develop.


While a medical examination was completed for all three patients, each was insufficient to determine if the patients were suffering from emergency medical or psychiatric conditions.