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Based on reviews of medical records, policy and procedures, ambulance report, facility incident Report Form, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's Emergency Department (ED) including ancillary services routinely available to the ED, to determine whether or not an EMC (Emergency Medical Condition) existed for 1 (#1) of 20 sampled patients who presented to the ED via ambulance on 2/212024 at 2:36 P.M., with suicidal ideations (SI), and with plans to hang himself. The patient reported to hospital ED staff that he was having SI for three days and felt that he was getting closer to harming himself and had attempted to kill himself more than six months ago. The patient requested he be evaluated for inpatient hospitalization to keep him safe. The patient's behavioral assessment was completed by a Licensed Professional Counselor (LPC) who determined Patient #1 was a "Moderate Imminent Risk for suicide" and documented the patient's "judgement was poor." The medical record did not contain evidence that the MSE included collateral information from the patient's family member (sister), who was identified in the medical record as somebody he contacted frequently about his suicidal thoughts, unstable housing, and financial barriers. There was not documentation that patient #1's suicidal thoughts, plans, and attempt prior were assessed or contextualized as part of his risk assessment during this visit. The MSE also identified that patient #1 had diabetes was out of insulin for three weeks but failed to evaluate whether this complaint was associated with an EMC. Patient #1 was discharged to self with a diagnosis of "suicidal ideation" after his MSE was concluded on 2/21/2024 at 3:21 PM (45 minutes after arrival). On 2/21/2024 at 6:02 P.M., Patient #1 was found after discharge in the ED waiting room restroom unresponsive from an apparent self-inflicted hanging. Resuscitation efforts were unsuccessful, and Patient #1 was declared deceased on 2/21/2024 at 6:11 P.M.

Refer to finding in Tag 2406

Based on reviews of medical records, policy and procedures, ambulance report, facility incident Report Form, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's Emergency Department (ED) including ancillary services routinely available to the ED, to determine whether or not An EMC (Emergency Medical Condition) existed for 1 (#1) of 20 sampled patients who presented to the ED via ambulance on 2/212024 at 2:36 P.M., with suicidal ideations (SI), and with plans to hang himself. The patient reported to hospital ED staff that he was having SI for three days and felt that he was getting closer to harming himself and had attempted to kill himself more than six months ago. The patient requested he be evaluated for inpatient hospitalization to keep him safe. The patient's behavioral assessment was completed by a Licensed Professional Counselor (LPC) who determined Patient #1 was a "Moderate Imminent Risk for suicide" and documented the patient's "judgement was poor." The medical record did not contain evidence that the MSE included collateral information from the patient's family member (sister), who was identified in the medical record as somebody he contacted frequently about his suicidal thoughts, unstable housing, and financial barriers. There was not documentation that patient #1's suicidal thoughts, plans, and attempt prior were assessed or contextualized as part of his risk assessment during this visit. The MSE also identified that patient #1 had diabetes was out of insulin for three weeks but failed to evaluate whether this complaint was associated with an EMC. Patient #1 was discharged to self with a diagnosis of "suicidal ideation" after his MSE was concluded on 2/21/2024 at 3:21 PM (45 minutes after arrival). On 2/21/2024 at 6:02 P.M., Patient #1 was found after discharge in the ED waiting room restroom unresponsive from an apparent self-inflicted hanging. Resuscitation efforts were unsuccessful, and Patient #1 was declared deceased on 2/21/2024 at 6:11 P.M.

Findings included:

A hospital document titled, "Facility Incident Report" dated 2/22/2024 was reviewed. The section of the incident report titled "Details of Incident' revealed in part, "Pt. [Patient] #1 presented at Grady Health System via EMS [Emergency Medical Services] at 5:17 P.M. on 2/21/2024. His chief complaint was suicidal ideation with a plan ...has a history note since 2012 of suicidal ideation with multiple visits to facilities in Georgia and Ohio. He was homeless and had a significant history of alcoholism. He was triaged and screened and placed in PES [Psychiatric Emergency Services], the Grady Health System psychiatric emergency department. He was seen by a resident and an attending physician and cleared for discharge with after care plan. According to video surveillance he left the hospital at 4:00 P.M., he came back in the ED at 4:08 P.M. without speaking to anyone and entered the bathroom at which time he used his belt as a ligature and hung himself. Another patient attempted to use the bathroom at 5:45 P.M. and the door was forced open. CPR (cardiopulmonary resuscitation) was started and continued till time of death at 6:11 P.M.". Further review revealed the County Medical Examiner was notified and involved. The facility took steps to prevent further incidents by assigning a RCA (Root Cause Analysis- the process of discovering the causes of problem in order to identify appropriate solutions) team on 2/22/2024.





The Ambulance report (Patient Care Record) dated 2/21/24 at 1:55 P.M. for Patient #1 was reviewed. The report revealed the patient's "Chief Complaint" SUICIDAL IDEATIONS BY HANGING." The patient's level of distress was listed as "Mild." The patient's signs and symptoms were documented as "Depression (Primary), Hyperglycemia (elevated blood pressure sugar levels), and Suicidal ideations," patient #1 vital signs were listed as 160/74 (Normal blood less than 120), Heart Rate 90, Respiratory rate -16, oxygen level was 98 % on room air, blood glucose level was 351 (normal blood glucose level-80 to 100 mcg/dl); Pain level of 3. The patient was noted to be awake, alert and oriented to name, person, and date, and was moving all extremities. Review of the Narrative section of the report revealed in part the following, "66-year-old male behavioral disorder, upon arrival we found ...sitting on a bench outside this location. He states he is under a lot of stress; he is very depressed and is now suicidal with a plan of hanging himself. He C/O (complains of) mild chest pains secondary to 2 broken ribs from a month ago ... He was able to walk over to the ambulance ... we started an 18 GA (gauge) INT (intermittent needle therapy) in the left forearm and started Normal Saline ...gave Grady report ...got him in the ED (Emergency Department) ...registered and triaged ...and turned him over to staff for further evaluation."

A review of Patient (P) #1's medical record revealed that he arrived at the facility's emergency department on 2/21/24 at 2:24 P.M., via ambulance. Review of the ED notes the ED Nurse documented in part, "Chief Complaint: Patient presents with Suicidal + (positive) SI (Suicidal ideation) w (with)/ plan to hang himself. He has had an attempt previously where he tried hanging and stabbing himself over a year ago." Further review the patient was triaged as a level of 2, emergent, (requires an immediate nursing assessment and rapid treatment and includes patients who are in a high-risk situation).

A review of an Emergency Medicine Rapid Medical Examination Note for Patient (P) #1 dated 2/21/24 at 3:17 p.m. by medical doctor (MD) BB revealed that P#1's blood glucose level (level of glucose found in the blood) was 351 (normal was 80-100 mcg/dl) with EMS and the blood glucose level was 275 in triage. P#1 reported polydipsia (thirst) and urinary frequency. P#1 reported that he had been out of insulin (medication used to treat diabetes) for three weeks. There was no documentation in the medical record to indicate that the hospital made use of its capabilities and services routinely available to the emergency department (such as but not limited to, laboratory tests) to further assess whether Patient #1's abnormal glucose level was a manifestation of an emergency medical condition. Documentation by the ED Physician in the "Narrative" section revealed in part, "Patient was initially found to have a BG (Blood glucose) of 351 so was brought the zones for fluids before being medically cleared and brought to PES for psychiatric evaluation."

Continued review of the Emergency Medicine Rapid Medical Examination Note revealed, "Patient said that he is "not good" because his depression and suicidal thoughts have been bad for 3 (three) days. Patient said that he called for help today because the thoughts were getting stronger, but God doesn't want him to hurt himself. Patient noted that faith is very important to him. Patient endorses his last alcoholic drink to be a couple of weeks ago and denies any other recent substance use ...Patient says that he has been staying at a group home where he pays rend on the 3rd each month. However, 2 (two) days ago patient was not able to reach his money account. When asked if he can return to this group home, he said that he can't because if he does he will kill himself. Patient went this morning to get a new ID (identification) after losing his but needed a birth certificate, so he ordered one online. Patient has a sister ...that he talks to regularly (most recently today)."


MD BB noted that per a chart review, P#1 had numerous visits to the facility and other hospitals with similar presentations and complaints with history of housing instability and alcohol use. Continued review of the note revealed that a medical screening examination (MSE) was conducted by MD BB that revealed P#1 was alert, calm and cooperative, and engaged with interviewer. P#1 reported that his mood was "not good". P#1 was documented to be "coherent, organized, and goal directed".

The section of the note titled, "Assessment/Diagnosis(es) MD BB documented in part, "1. Homelessness: Patient is at higher overall risk for suicide given their current homelessness, chronic illness, and ongoing substance use. Patient is also at risk for manipulative self-harm. However, suicide is best addressed with substance treatment and connection with psychotherapy and not short term psychiatric. There may be a component of secondary gain as the patient remains homeless with limited resources and has not followed through with outpatient planning."


P#1 was discharged to self and provided with contact information for outpatient psychiatric resources to the Georgia Crisis and Access Line and Grady Mental Health Clinic. (Access to Crisis Services - provides telephonic crisis intervention services, Dispatch mobile teams, and assist individuals in finding an open crisis or detox bed across the state).

Medical record review revealed that on 2/21/2024 at 3:28 P.M. that Licensed Professional Clinician (LPC)-CC was authorized by Physician AA (Attending Medical Doctor) to perform an ED SRA [Suicide Risk Assessment -comprehensive assessment that determines an individual's risk is for suicide at a given point and time]. Documentation by LPC revealed in part the following SRA questions were asked, ".. Have you actually had any thoughts about killing yourself: Yes; Have you thought about how you might do this?: Yes ("Hang self or stab myself."); Have you had any intention on acting on these thoughts of killing yourself? Do you intend to carry out this plan: No ...Modifiable risk factors: Current instability in environment/psychosocial factors and Active alcohol/substance use disorder. Protector factors: Future orientee/goal directed, Connection religious beliefs and Connection to family."



The section of note titled "History and Present illness, the LPC-CC documentation, revealed in part, "Patient #1 states he came to the hospital because he was getting "close ...When asked how r to doing it" ...Patient #1 reports faith is absolutely important to him which stopped him from completing suicide. ...When asked how the hospital could help him, he replied, "Keep me safe from harming myself. Send me to a program for mental illness. ... Patient #1 states he has a sister ...that he speaks to often. He reports no other support." There was no documentation in the medical record to indicate the facility staff attempted to contact the patient's sister or ask the patient to call his sister, to notify her of the facility's assessment that Patient #1 was determined a moderate risk for suicide, nor was she notified of Georgia Crisis line as stated in the facility's policy.


Further review of the medical record review revealed the Licensed Professional Clinician (LPC) CC documented in part, "Mental Exam (examination) "Appearance: Unkempt/disheveled; Behavior: Cooperative; Speech: Normal; Mood: "Not Feeling very good."; Affect: Blunted [a decreased ability to express emotion through facial expressions, tone of voice, and physical movements] ... Thought Process: Linear and Tight; Memory: Intact; Insight" Fair; Judgement: Poor".


The video footage related to Patient #1's initial visit (2/21/2024) was provided to the survey team during the investigation. Review revealed that that at 4:01p.m., Patient #1 was seen exiting the hospital's emergency department exterior entry holding paperwork in his hand.

A review of the medical record for the subsequent visit revealed that Patient #1 was evaluated un the ED again on 2/21/2024 at 6:02 P.M., and was pronounced deceased at 6:11 P.M.


A review of the facility's policy titled, "Assessment of Suicide Risk and Suicide Prevention," last revised 12/2023, revealed that the facility would provide guidelines for the assessment of suicide risk for patients receiving behavioral health services.
Assessment:
1. The Columbia-Suicide Severity Rating Scale (C-SSRS) or the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) will be completed for individuals. The SAFE-T assessment will solely be used within Psychiatric Emergency Services (PES):

o Prior to being discharged from the Psychiatric Emergency Services (PES) in the Emergency Department. ... B. Response to the C-SSRS and SAFE-T: The appropriate level of care is determined based upon the results of the assessments and the determination of imminent risk. Recommended responses are as follows: High Imminent Risk- inpatient hospitalization. Moderate Imminent Risk- refer to higher level of care or outpatient follow-up as appropriate - A Crisis Safety Plan will be developed for individuals deemed to be at moderate risk. Patient Education on the Crisis Safety Plan will be documented in the electronic medical record (EMR) to include patient's expressed likelihood to use the Safety Plan ...C. Monitoring:
o Individuals served in the community, who are at moderate or high risk for suicide must address the treatment of suicidality in their treatment plans.
D. Provision of Suicide Prevention Information
o When an individual at risk for suicide leaves the care of the organization (whether at discharge from a program or after the provision of a service), suicide prevention information, such as the contact information for the Georgia Crisis and Access Line, is provided to the individual and his or her family. Provision of this information is documented in the patient record.


The facility's policy titled, "EMTALA Policy - Medical Screening Examination, Central Log, On-call coverage, and Signage," last reviewed 9/2023, "It is the policy of the facility to provide an appropriate Medical Screening Examination (MSE) when an individual comes to its Dedicated Emergency Department (DED) and:
1. The individual or representative acting on the individual's behalf requests and examination or treatment for a medical condition .... Procedure: When an MSE (medical Screening examination) is Required: Grady must provide an appropriate MSE within the capability of the hospital's DED (Dedicated Emergency Department) including ancillary services routinely available to the DED, to determine whether or not an EMC (Emergency Medical Condition) exists: (i) any individual ...who requests such an examination ... An MSE shall be provided to determine whether or not the individual is experiencing an EMC ...Extent of the MSE...b. Definition of MSE ...As MSE is the process required to reach, within reasonable clinical confidence, the point at which it can be determine whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of Grady. C. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer ...e. Extent of MSE varies by presenting symptoms. The MSE varies by presenting symptoms and may vary depending on the individual's signs and symptoms: i. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures ... iii. Individuals with psychiatric symptoms: The medical record should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicate danger to self or others."


During an interview on 3/4/24 at 2:19 p.m. in the conference room, Medical Doctor (MD) BB said that she has been a general psychiatric medical resident for almost one year. MD BB said that once patients are triaged, a psychiatric complaint is identified and deemed medically stable, then are then sent to the ED's psychiatric emergency services (PES) area where staff formulate a treatment plan for the individual and decide on the disposition of the patient.

MD BB recalled that a chart review was performed on P#1 before the plan of care was discussed, and MD BB noted that P#1 was a high utilizer at multiple emergency departments (EDs) in the past for the same complaint and was discharged numerous times. MD BB recalled that P#1's housing status was unclear as he reported he was staying in a group home (GH) but was not living in the GH for a couple of days due to financial issues. MD BB recalled that a list of shelter resources was given to P#1 along with OP (Outpatient) resources for housing assistance. MD BB recalled that P#1 sat in the hall spot chair and did not require the use of a room in the PES prior to discharge.

During an interview on 3/5/24 at 9:35 a.m. in the conference room, MD AA said that he has been practicing psychiatric medicine for four years and has been an Attending for almost nine months. MD AA recalled reviewing P#1's chart who had a history of chronic alcohol and substance usage and multiple ED visits due to SI. MD AA recalled P#1 presenting to the PES after receiving medical treatment for hyperglycemia (high-blood sugar) and intravenous (IV) fluids with an RN.
MD AA recalled that he wrote an addendum the night of the event to summarize what was done in the PES that day for P#1.

During an interview on 3/5/24 at 1:57 p.m. in the conference room, Licensed Professional Clinician (LPC) CC said that she has been an LPC since 2013. LPC CC said that LPCs assess and assist with determining along with the physician if a patient should be admitted to the facility or discharged.

LPC CC recalled P#1 that he presented to the PES for a SI complaint after being treated for hyperglycemia. LPC CC recalled that P#1 reported that he was not doing well because he was depressed and suicidal. LPC CC recalled that P#1 reported that he was staying at a group home (GH) but got put out because he could not pay rent. LPC CC recalled that P#1 reported that he had been staying at the GH for at least two days. LPC CC recalled asking P#1 if he could stay with his sister and P#1 told her that he could not. LPC CC recalled asking P#1 if he would do anything to hurt himself and P#1 reported that if he would hurt himself, it would be to hang himself or by another method. LPC CC said that she was not sure why the team did not ask more about where P#1 would go once discharged and felt that the team could have asked more on this matter when thinking about it now.

LPC CC said that she did perform a suicide risk assessment on P#1 and that he was a moderate risk, but this is based on his chronic history and risk factors. LPC CC said that per facility policy patients with a moderate risk can be discharged.

The facility failed to ensure that patient #1 was provided an appropriate medical screening examination during his initial ED visit on 2/21/2024 at 2:36 P.M. The facility failed to follow its "Assessment of Suicidal Risk and EMTALA policies failing to make use of the hospital's capability (including diagnostic testing to determine whether the patient's observed abnormal glucose upon arrival in the setting of being out of insulin for 3 (three) weeks, was a manifestation of an emergency medical condition), and failed to obtain collateral information from Patient #1's identified family member to determine whether or not there was an emergency medical condition.