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Based on observation, policy review, medical record review, document review, and interview, in 1 of 20 medical records reviewed, it was determined that the emergency department (ED/comprehensive psychiatric emergency program (CPEP) staff failed to ensure Patient #1 had access to appropriate resources for a safe discharge.

Cross Reference:
482.55(a)(3)- Emergency Services Policies

Based on policy review, medical record review, and interview, in 1 of 20 medical records reviewed, it was determined the emergency department (ED)/comprehensive psychiatric emergency progam (CPEP) staff failed to ensure Patient #1 had access to appropriate resources for a safe discharge after three presentations on 05/01/25. After the 3rd discharge from Hospital #1, Department of Public Safety (DPS- security and peace officers) Officers brought Patient #1 to another hospital (Hospital #2) for psychiatric evaluation/treatment due to continued behaviors and inability to care for self.

Findings include:

Review of the policy "Patient Discharge Guidelines," effective 10/24/23, revealed it is the facility's policy to review each patient being discharged from the ED to determine the patient's capacity to return safely to their place of residence. The facility will provide appropriate collateral referrals (i.e. home health care), resources (i.e. clothing, shelter), and transportation in support of safe patient discharge. The procedure includes the patient is dressed in weather appropriate clothing, the patient's access to their residence has been confirmed, and appropriate transportation has been confirmed or arranged, with social work assisting as needed. If the nurse identifies a barrier to safe discharge the primary nurse should consult with the social work to complete a safe and adequate discharge for the patient. The social worker and/or primary nurse arranges required services for the patient, dependent upon the patient's risk profile. When resources for safe patient discharge cannot be secured at the time of patient ' s medical readiness for discharge, the patient will remain in the ED until they can safely be discharged. Documentation of efforts (along with barriers) to discharge will be in the patient's medical record. For challenging discharges, contact social work as early as possible. Social work will attempt to arrange lodging in an area shelter.

Review of the policy "Discharge of Patients from CPEP" effective 03/24/25, revealed patients discharged from the CPEP are evaluated to determine the patient's capacity to return safely to their place of residence. CPEP will provide appropriate referrals, resources, and transportation and support of safe patient discharge. CPEP provider makes the decision to discharge the patient after the initial face to face assessment or the full evaluation. Discharge planning includes completing a safety plan and include a copy with the after-visit summary. Appropriate referrals will be completed to address the needs related to mental health, substance use, and other social determinants of health. Collateral information will be updated, the patient will be told of the updates and follow up plan. Upon discharge, ensure the patient is appropriately dressed for the weather and document accordingly. Ensure the patient can access their residence, they have proper transportation upon discharge, and there are specific transportation requirements for patients identified as vulnerable persons.

Review of the medical record at Hospital #1 for Patient #1, dated 05/01/25 (1st presentation), revealed:
- At 12:51 PM, Patient #1 arrived at the emergency department. A note by Staff (AA), CPEP Nurse Practitioner, revealed Patient #1 was dropped off at the hospital after they were released from jail. Patient #1 was there voluntarily and not on Mental Hygiene Trasnsport (MHT) status. Patient #1 denied having any suicidal or homicidal thoughts and had no desire to harm themselves. Patient #1 stated they were hurt by their significant other, and had various bruising on their arms from their significant other, but declined medical treatment. Patient #1 stated that they were at the hospital to obtain medication for their significant other. Patient #1 repeatedly asked for their mother, which Staff (AA) reminded Patient #1 they could contact their mother on their own. Patient #1 stated they were sad because their brother had died, which is something that happened many years ago and is known as a reason for their emotional distress. Patient #1 denied having any other psychiatric needs. Patient #1 is well known to community CPEP/ED services, presenting often for various psychiatric and medical complaints in the context of poor coping, and seeking shelter or food. Patient #1 is known to behaviorally dysregulate (difficulties in controlling or regulating behaviors) inside and outside of the hospital setting. Patient #1 was connected with Strong Ties ACT (Assertive Community Treatment- community care management program which is the highest level of care prior to requiring inpatient services), who report that they believe that Patient #1's presentations are behavioral in nature. Patient #1 was to be discharged with passes for public transportation and was provided information for two homeless shelters.
- At 01:25 PM, a clinical evaluator note by Staff (BB), Registered Nurse, revealed a secure chat conversation was held with the Strong Ties ACT Nurse Practitioner, who reported Patient #1 could be discharged to a homeless shelter if they are not banned from there. Patient #1 had an appointment with Strong Ties ACT team scheduled for 05/06/25. Staff (BB) attempted to contact the homeless shelter but was unable to reach staff there.
- At 01:33 PM, the CPEP disposition note by Staff (BB), Registered Nurse, revealed Patient #1 was being discharged to the community. Patient #1 was homeless and there was no family notification of discharge. Patient #1 had their own bus pass. Belongings and valuable were given to Patient #1.
- At 02:01 PM, a CPEP triage note by Staff (CC), Registered Nurse, revealed Patient #1 began making nonsensical statements and attempted to relieve themselves of the floor three times. Patient #1 was positive for confusion and decreased concentration. Patient #1 denied suicidal ideations and was noncompliant with the rest of the triage process.
- At 02:05 PM, a CPEP note by Staff (BB), Registered Nurse, revealed staff had difficulty redirecting Patient #1's behaviors despite positive re-enforcement. Staff (BB) and two other CPEP registered nurses escorted Patient #1 off the unit and Patient #1 attempted to pull their pants down in the elevator. Staff (BB) and staff escorted Patient #1 to the front ED entrance. Patient #1 again started to pull their pants down while raising their shirt. Staff (BB) informed Patient #1 that willingly exposing their genitals to others, including children present, would result in felony charges related to indecent exposure to minor children as well as public indecency. Patient #1 immediately pulled their pants back up, covering themselves with their shirt and hospital gown. Once to the front of the hospital, Staff (BB) gave Patient #1 their discharge paperwork, bus passes, and a copy of the "Interim Ban from University of Rochester Properties," that DPS issued to Patient #1. Staff (BB) explained the criteria and nature of the ban. Patient #1 proceeded to look directly at Staff (BB), then threw all the paperwork and bus passes about the ground. DPS quickly presented, re-iterated the ban information while instructing Patient #1 to leave the premises. Patient #1 took a few steps, started to disrobe then touch themselves inappropriately. At that time, Staff (BB) and CPEP staff left the situation to return to their unit.

Review of the medical record at Hospital #1 for Patient #1, dated 05/01/25 (2nd presentation), revealed the following:
- At 03:20 PM, the 9.41 Mental Health Transport (MHT- Section 9.41 of the mental health law authorizes police or peace officers to remove an individual who appears to be mentally ill and is conducting themselves in a manner likely to result in serious harm to self or others, from the community to a hospital for a psychiatric evaluation) document by a local law enforcement officer, indicated at approximately 02:45 PM, the police officer observed Patient #1 sitting in the back of a public bus naked. Patient #1 then began screaming, hitting themselves and biting their arms. Patient #1 could not communicate with responders on scene, refused any help, and would not get off the bus. Patient #1 was eventually escorted from the bus, placed under 9.41 status and transported to Hospital #1. The order indicated Patient #1 was a danger to self/others were, they were unable to care for self and they attempted to hurt/kill self/others.
- At 03:46 PM, a triage note by Staff (EEE), ED Registered Nurse, indicated Patient #1 was brought in on an MHT for a psychiatric evaluation. Patient #1 was on the bus naked, attempting to hit other people on the bus. Patient #1 denied suicidal/homicidal ideation.
- At 04:02 PM, a CPEP provider triage and referral note by Staff (K), CPEP Nurse Practitioner, revealed Patient #1 arrived at CPEP with police on a 9.41 MHT status for a psychiatric evaluation. Patient #1 was well known to CPEP as they were a high utilizer of ED/CPEP services. Patient #1 was last seen in CPEP earlier in the day and was discharged to a homeless shelter. Patient #1 presented after being observed unclothed, screaming, and hitting their self. Patient #1 has presented to the ED or CPEP 25 times in the past 30 days and was last admitted to inpatient psychiatric unit from 01/30/25-02/14/25 with an altered mental status (noticeable change in a person's level of awareness, cognition, or consciousness compared to their normal baseline) and medication nonadherence (failure to take medications as prescribed by their healthcare provider). Patient #1 was currently connected with Strong Ties ACT for outpatient mental health care. Staff (K) observed Patient #1 sitting in a chair exhibiting behavioral control but refusing to answer why they were back in the hospital. Staff (K) re-enforced that Patient #1 should not disrobe in the public setting and informed Patient #1 that they would again be discharged to go to the homeless shelter. Patient stated "no, no, no" and then covered their head with a blanket. Patient #1 presented with no evidence of mania, psychosis, intoxication or withdrawal symptoms. Staff (K) indicated Patient #1's presentation was most consistent with ineffective individual coping in the context of poor distress tolerance, housing insecurity, limited coping skills and is not consistent with the signs, symptoms, or timeline of a major mood or thought disorder that would benefit from or require an inpatient admission. Patient #1 would benefit from a less restrictive setting. Staff (K) had a secure chat conversation with Strong Ties ACT Nurse Practitioner, who had no new information and advised that Patient #1 return to the homeless shelter. Patient #1 had an appointment with Strong Ties on 05/06/25 (five days later). No additional mental health services are required because Patient #1 is enrolled in appropriate treatment. Plan for Patient #1 was to refrain from taking clothes off in public settings and return to shelter via bus pass.
- At 04:24 PM, a discharge note by Staff (BB), Registered Nurse, revealed Staff (BB) and Staff (K), CPEP Nurse Practitioner, observed Patient #1 who was sitting calmly in a reclining chair, appropriately covered with shirt and paper scrub bottoms. As Staff (BB) and Staff (K) approached, Patient #1 immediately started pulling up their shirt, rambled incoherently, rubbing their eyeball with their bare fingers and then put their fingers in their mouth. Staff (K) completed their evaluation and informed Patient #1 that they would again be discharged. Patient #1 then stated "no, no, no", then sat back in the chair and crossed their arms. DPS officers assisted with placing Patient #1 in a wheelchair and moving them to the front of the hospital. Patient #1 continued to attempt to touch themselves inappropriately in the presence of DPS officers. Patient #1 was provided bus passes and after visit summary.

Review of the medical record at Hospital #1 for Patient #1, dated 05/01/25 (3rd presentation), revealed the following:
- At 05:35 PM, the 9.41 Mental Health Transport (MHT) document by Staff (DD), DPS Officer, revealed Staff (DD) arrived to find Patient #1 naked on the street yelling at cars. Patient #1 was on the sidewalk naked, crying., could not answer any questions, and refused all directions. Staff (DD) and other DPS officers attempted to assist Patient #1 with getting their clothes on, but Patient #1 refused. Eventually Patient #1 was wrapped in a blanket. Patient #1 stated that they wanted to die and was not making sense. Patient #1 stated that they needed to go find their sibling, pointing and walking towards a nearby cemetery. Patient #1 was at a high traffic intersection at a very busy time of day. Based on Patient #1's behavior, inability to follow instructions or answer questions, and putting themselves in a dangerous situation, Patient #1 was placed under a 9.41 MHT status and taken back to Hospital #1's ED via wheelchair.
- At 05:51 PM, the ED triage note by Staff (EE), Registered Nurse indicated Patient #1 was brought in by DPS on a MHT after being found naked at the bus stop. Patient #1 was seen wandering around, speaking incoherently. Patient #1 was discharged less than an hour ago. Patient #1 was seen by ED physician in triage. Unable to obtain vital signs.
- At 05:46 PM, a note by Staff (J), ED Attending Physician, revealed Patient #1 presented in the company of DPS officers after being found naked at the bus stop. Patient #1 continued to speak incoherently and talk over Staff (J). Patient #1 was not cooperative and would not follow commands. There was no evidence of trauma and Patient #1 appeared at their well-known baseline. The physical exam revealed Patient #1 appeared non-toxic (suggests the individual appears generally healthy and stable), was alert, speaking incoherently, and unable to assess for orientation. Patient #1 remained uncooperative, continued to attempt to reach down their pants and expose themselves. Patient #1 is homeless and has frequent ED presentations after stripping naked outside of the hospital. Staff (J) had seen Patient #1 within the past couple of hours when discharged from CPEP. The CPEP team felt that Patient #1 was malingering (the intentional fabrication or exaggeration of physical or psychological symptoms for an external gain) and displaying personality disorder not indicative of acute psychiatric decompensation and not likely benefit from further hospitalization. Patient #1 otherwise appeared at their baseline and would be discharged back to the community.
- At 06:16 PM, Patient #1 was dismissed from the ED. There was no departure condition, after-visit summary, collateral contact, or social work involvement documented in this medical record for this presentation.

Review of the "Mental Health Transport 9.41" document, dated 05/01/25 at 07:45 PM, by Staff (V), DPS Officer, revealed Patient #1 was recently taken to Hospital #1 on a 9.41 MHT status, but was immediately discharged and was not evaluated. Patient #1 is well known to CPEP and per staff, at their baseline and was not having a psychiatric problem, but more of a behavioral problem. Patient #1 had been discharged without proper clothing, still wrapped in the blanket that DPS provided on the previous 9.41 MHT. Due to Patient #1 still being naked, rambling unintelligibly, and refusing to give officers and information, the PIC team (Person in Crisis- a unit that responds to individuals experiencing mental health crises or other social and community emergencies) was called. Patient #1 was evaluated by a PIC team member who reported Patient #1 needed a higher level of care then PIC could provide and that Hospital #1's CPEP was refusing to provide care. The PIC team recommended Patient #1 be placed on a 9.41 MHT status and transported to a different hospital (Hospital #2). At 06:51 PM Staff (V) placed Patient #1 under 9.41 MHT status and Patient #1 was transported to Hospital #2. The care and custody of Patient #1 was turned over to the medical staff at Hospital #2. The order indicated Patient #1 was a danger to self/others were, they were unable to care for self, and they placed self in dangerous situation.

Review of the medical record at Hospital #2 for Patient #1, from 05/01/25 to 05/02/25, revealed the following:
- On 5/01/25 at 08:15 PM, a note by Staff (AAA), ED Attending Physician, revealed Patient #1 presented to the ED after being placed under a 9.41 MHT status three times that day (at Hospital #1). Patient #1 was walking naked, taken to Hospital #1 and were discharged by their CPEP. Hospital #1 DPS officers contacted the PIC team after Patient #1 had been discharged the final time by Hospital #1's CPEP over the phone. Patient #1 was placed under a 9.41 MHT status and brought to this ED. Patient #1 was seen by psychiatry and case was discussed with Staff (BBB), Psychiatrist who recommended discharge of Patient #1 in the morning to Strong Ties ACT team or emergency housing. Likely these visits were related to Patient #1's ongoing issues of developmental delay and personality disorder. Staff (BBB) stated there was no need for an acute psychiatric admission. There was no emergency housing available that night, so Patient #1 was moved to the crisis intervention unit (CIU). Upon arrival in the CIU, Patient #1 started wandering around spitting at security staff and exposing themselves. Patient #1 was placed in physical restraints and medicated for agitation. Unfortunately, Patient #1 continued to yell, wander, exposing themselves and spitting on security staff when they were released from physical restraints. Patient #1 was placed back in restraints and care was transferred to the oncoming ED provider.
- On 05/02/25 at 07:29 AM, a note by Staff (CCC), ED Attending Physician, revealed they had a detailed discussion with Patient #1 about there being no clinical indication for further emergent intervention or inpatient treatment. Verbal and written discharge instructions were provided. Patient #1 was encouraged to return for any worsening symptoms, persisting symptoms, or any other concerns. Patient #1 was provided the opportunity to ask question and was then discharged directly to the Strong Ties ACT center team.

Interview on 06/05/25 at 02:45 PM with Staff (V), DPS Peace Officer, revealed they were made aware Patient #1 initially presented to the ED on 05/01/25 (1st presentation) by local law enforcement after being released from jail. Patient #1 was discharged from Hospital #1's ED with a bus pass and went to a bus shelter. Patient #1 was brought to Hospital #1 again after disrobing and yelling at traffic (3rd presentation). Staff (V) was instrumental in finding clothing for Patient #1 obtaining pants, shirt, and shoes, and assisting with dressing. Patient #1 arrived at 05:47 PM (3rd presentation), was evaluated by the ED provider and the registered nurse. The ED provider told Staff (V) Patient #1's behavior was at baseline (normal). The ED RN called the CPEP, and was told CPEP would not accept Patient #1. Social work was contacted but had further options, and Patient #1 was discharged. Staff (V) spoke with their DPS Sergeant, who confirmed Patient #1 was banned from multiple shelters and had no other resources available. At 06:02 PM, Staff (V) assisted Patient #1 into their police vehicle outside the hospital entrance and called the PIC team for guidance. The PIC team informed Staff (V) that Patient #1 was banned from all shelters and there were no other options available. The PIC team recommended Patient #1 be placed under MHT status and taken to another facility (Hospital #2) as it appeared Patient #1 required a higher level of care that Hospital #1's CPEP is refusing to provide. Staff (V) drove approximately one block away to be off Hospital #1's property and placed Patient #1 under a 9.41 MHT status to transport them to Hospital #2.

Telephone interview on 06/10/25 02:45 PM with Staff (DD), DPS Officer, revealed on 05/01/25. Staff (DD) received a call around 05:30 PM to respond to a person unclothed, walking, screaming, and crying on the sidewalk not far from Hospital #1. Staff (DD) received assistance from Staff (V), DPS Officer, who spoke Spanish. DPS Officers attempted to de-escalate Patient #1 and calm them down. Patient #1 was not directable and was speaking words that did not make sense in both languages. Patient #1 was put unclothed in the back of the car as the intersection was exceptionally busy at the time. Staff (DD) called the hospital to bring blankets to cover Patient #1 who had exited the back of the car. Patient #1 would not get back in the car and was unable to respond to questions. Patient #1 was placed under a 9.41 MHT status. Patient #1 was covered with a blanket and escorted back to the hospital in a wheelchair. Staff (DD) drove near the facility so they could type up the 9.41 MHT documentation and print it. Before the paperwork was printed, Staff (DD) observed Patient #1 outside, already discharged. Patient #1 was outside the ED entrance of Hospital #1 with additional DPS Officers. One of the additional DPS officers went back to the ED to speak with the social worker. DPS Officers on site were advised that Patient #1 had exhausted community resources, and no housing options were available. The PIC team was contacted by a DPS Officer and promptly arrived. PIC team members spent approximately 30 minutes trying to communicate with Patient #1 with little success. The PIC team advised the DPS Officers that Patient #1 had exhausted community housing resources and was banned from all shelters or emergency housing. The PIC team recommended Patient #1 be placed under a 9.41 MHT status and transported to another hospital (Hospital #2) for treatment. Staff (DD) was aware Patient #1 was already seen earlier in the day for the same reasons, was medically cleared, and discharged (at Hospital #1). Staff (DD) was concerned for Patient #1 ' s safety, as traffic was very busy in the area, and concerned that Patient #1 would wander into traffic. Also, because Patient #1 was only wrapped in a blanket. Staff (DD) was familiar with Patient #1 but in the past, but Patient #1 had been re-directable. On this day they were not directable and appeared to not be at their baseline behavior. If Patient #1 had a place to go after discharge they would have driven them there to ensure safety. Staff (DD) stated Patient #1 has a community care plan that began after this day, and they have not seen Patient #1 since then.

Interview on 06/11/25 at 02:45 PM with Staff (ZZ), DPS Sergeant, revealed the initial call came in to assist Patient #1 who was standing in a busy traffic area bordering Hospital #1's property, at little after 05:00 PM. Patient #1 was not wearing clothing and had no property or paperwork. Staff (ZZ) was familiar Patient #1. Patient #1 was directed to put their clothing on. Patient #1 replied in a combination of English and Spanish language that sounded like "gibberish." Patient #1 was in a busy intersection area, was disrupting traffic with their behavior, wearing no clothing. DPS covered Patient #1 with blankets. DPS officers attempted to direct Patient #1 out of the immediate area of traffic. Staff (ZZ) was aware of a previous 9.41 MHT transportation that day initiated by the local law enforcement, when Patient #1 was physically removed without clothing from a public bus (2nd presentation). Patient #1 was brought back to the hospital by the other DPS officers. When Staff (ZZ) arrived back to Hospital #1, Patient #1 was immediately discharged again. A different DPS officer went into Hospital #1 asking for clothing and the PIC team was called for assistance. Three PIC team members showed up to help and stated there were no community resources available for housing. The PIC team explained the Patient #1 was still in need of assistance, so the PIC team supervisor was called. The PIC team and DPS officers agreed to send Patient #1 to a different hospital (Hospital #2).. Staff (ZZ) did not think it was safe for Patient #1 to be discharged to the community as they were not directable, they continued to disrobe, continued to yell at cars driving by, it was raining, and traffic near the bus stop was extremely busy at this time of day. An ambulance was called for transportation. After waiting approximately 30 minutes Staff (ZZ) made the decision to allow a DPS officer to transport Patient #1 to Hospital #2 in their patrol car.

Interview on 06/05/25 at 03:00 PM with Staff (J), ED Attending Physician, revealed Patient #1 arrived at the ED multiple times on 05/01/25. Patient #1 went to CPEP once, and the second time the psychiatric provider came to the ED to evaluate Patient #1 prior to discharge. When Patient #1 arrived at the ED a third time for public exposure, they presented in a similar manner. Staff (J) evaluated Patient #1 and found no acute changes or further emergent complaints from previous discharge. Patient #1 was discharged without a call to CPEP and has the discretion to use their clinical judgement to determine if CPEP needs to be consulted.

Interview on 06/05/25 at 04:00 PM with Staff (K), Nurse Practitioner, revealed they recall seeing Patient #1 in the medical ED during the 2nd presentation on 05/01/25. Patient #1 speaks Spanish and can speak English, but it can be unclear jumping from thought to thought and sounding like gibberish. Staff (K) has not seen Patient #1 disrobe or become violent although this is noted in the medical record as common behaviors. Staff (K) stated with multiple admissions on the same day, and Patient #1 already seen in the CPEP, it would be typical for Patient #1 to be seen in the medical ED instead of bringing them to CPEP. Patient assessments include determining safety, to clear them for discharge, to assist with collateral knowledge, to provide bus passes, and to see if further admission to the CPEP is required. Patient #1 was at their baseline behavior when seen on 05/01/25 during the 2nd presentation to the facility and did not meet admission criteria. Patient #1 was directable. Staff (K) does not think Patient #1 disrobing in public is a danger to herself or others. Patient #1 was given the proper resources and instructions to follow up with Strong Ties assertive community treatment service (ACTS) team (on 05/06/25) which was appropriate.

Interview on 06/06/25 at 12:35 PM, with Staff (Z), Senior Clinical Evaluator, revealed Patient #1 was well known. Staff (Z) did not think the discharge of a naked patient obstructing traffic was necessarily safe, but the behavior did not warrant a psychiatric admission.

Telephone/video interview on 06/06/25 at 09:00 AM with Staff (W), Primary Therapist, revealed they work as part of Strong Ties Assertive Community Treatment (ACT) Team, which is a county wide program that is the highest level of outpatient care an individual can receive prior to being admitted for inpatient care. The ACTS team will assist by bringing patients to appointments, scheduling appointments, providing injections, delivering oral medications, and helping to arrange shelter. ACT is a transitional service for clients with or without housing and who frequent emergency room for basic physical or mental health needs. When services are required, CPEP is required to contact the team. The ACT team has on-call availability 24 hours a day, seven days per week. Patient #1 has been a member of their team for several years. Staff (W) was initially contacted around 10:00 PM on 05/01/25 by the facility Patient #1 had presented multiple times. After the 3rd presentation to Hospital #1, Patient #1 was brought to another hospital (Hospital #2). Hospital #2 notified Staff (W) that Patient #1 had presented under 9.41 MHT status. Hospital #2 was concerned as to why Patient #1 was brought to their hospital versus being brought back to Hospital #1, who has a higher-level care and more appropriate psychiatric program. Staff (W) informed Hospital #2 staff that Patient #1 has housing insecurity, and it was common for them to have dysregulated behavior when the discharge planning process is initiated. In addition, Patient #1 was banned from all local shelters except one on 05/01/25 and is now banned from all local shelters. Patient #1 can be selectively opportunistic to have their needs met, including premeditated violent attacks, therefore, Patient #1 is a risk to harm others or themselves. Patient #1 could also have negative behavior if they are admitted for secondary gain, to get their needs met. This reinforces the negative behavior that worked in their favor, and they will continue to express similar negative behaviors for secondary gain. Patient #1 does not fit the lower level of psychiatric care offered at Hospital #2.

Interview on 06/10/25 at 07:00 AM with Staff (CC), CPEP Registered Nurse, revealed they triaged Patient #1 in the CPEP on 05/01/25 (1st presentation to the hospital) who was requesting medication for their spouse and was upset when the CPEP would not provide it. Patient #1 proceeded to lower their pants and use the restroom on the floor. Patient #1 was instructed to pull up their pants, however they continued to repeat the same behavior. Patient #1 is known to be violent and instigate fights with other patients when agitated, resulting in restraints to be used. Patient #1 is known to disrobe as part of trying to get what they want. Staff (CC) stated they are unsure if the Strong Ties ACT team was contacted. Staff (CC) stated they were unaware of Patient #1 disrobing in public. When Patient #1 was discharged, Staff (CC) walked them down to the exit with DPS. Patient #1 was wearing paper scrubs upon discharge. Staff (CC) stated public indecency and disrobing is not appropriate, but they do not think it is unsafe. Patient #1 was aware to keep their clothing on in public. It is common for certain patients to arrive to the ED and CPEP multiple times per day. When a patient arrives under 9.41 MHT status, they must be evaluated by the CPEP.

Interview on 06/11/25 at 09:30 AM with Staff (AA), CPEP Nurse Practitioner, revealed Patient #1 was known to the service and Patient #1 arrived to the CPEP on 05/01/25 at their baseline behavior and dysregulated. Psychiatric technicians assisted Patient #1 to dress however, they do not recall seeing Patient #1 disrobe in CPEP and had not previously seen Patient #1 exhibiting these behaviors. A patient who receives Strong Ties ACT team will always have personal and professional collateral (obtaining additional information regarding an individual from outside sources- friends, relatives, outpatient case manages or providers) called upon presentation to CPEP. Staff (AA) did not remember speaking with a member of the Strong Ties ACT team during this admission and were unsure what their treatment plan recommendation was. Patient #1 appeared at their baseline behavior and did not meet admission criteria.

Telephone interview on 06/11/25 at 10:00 AM with Staff (EE), ED Registered Nurse, revealed Patient #1 is very well known to the service and arrived at the ED (3rd presentation) on 05/01/25 approximately 10 minutes after the previous discharge, covered in blankets provided by DPS after being found disrobed at the bus stop not far from the property. Staff (EE) stated they thought they called CPEP who advised them Patient #1 was seen within the last hour and could be discharged. The ED provider assessed Patient #1 and advised them they would be discharged as they were seen within the last hour.

Interview on 06/11/25 at 12:50 PM with Staff (BB), CPEP Registered Nurse, revealed Patient #1 is known to the service and on 05/01/25, Patient #1 presented to the ED. Patient #1 was deemed to have behavioral concerns and was inappropriate for psychiatric admission, therefore was discharged to the community clothed in paper scrubs with a plan to go to the single homeless shelter. Patient #1 presented with typical baseline behavior, although Staff (BB) had never seen them disrobe before. Staff (BB) assisted with discharging Patient #1. When Staff (BB) observed Patient #1 start to disrobe, they instructed Patient #1 to put their clothes back on, as there are minors in the community.