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Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #10) with all available and appropriate stabilizing treatment after presenting to the Emergency Department (ED) seeking medical care. Failure to provide all available and appropriate stabilizing treatment at the CAH's ED resulted in Patient #10 returning to the CAH's ED a second time, approximately five days later with similar symptoms that required transfer to another hospital for inpatient care. The CAH's administrative staff identified an average of 832 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Care of the Patient with an Emergency Medical Condition and Emergency Patient Transfer Policy," Last reviewed 2/19/21, revealed in part:

a. " ...if any individual ... comes by herself/himself or with another person to a Dedicated Emergency Department (DED), and request is made on the individual's behalf for examination or treatment of a medical condition by qualified medical personnel ..., the hospital will provide an appropriate medical screening evaluation within the capability of the hospital's DED, to determine whether or not an emergency medical condition exists.

b. " ...The hospital must provide for further medical examination and treatment as required to stabilize the individual."

c. " ...Emergency medical condition ... 'a medical condition manifesting itself by acute symptoms of sufficient severity (including ..., psychiatric disturbances ...) 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 to bodily functions; serious dysfunction of any bodily organ or part ...'"

d. " ...Stabilize ... with respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result ..."

2. Review of Patient # 10's clinic medical record revealed:

a. On 3/3/23 at 3:28 PM, Patient # 10 presented to the clinic with concerns of low blood sugar (BS). Their BS was high at 267 (normal range is 80-100 before eating) and blood pressure (BP) (the pressure of the blood in the circulatory system; normal range 120/80) was 146/86 (high). Patient # 10 reported to RN N that they would kill themselves if they were sent home. RN N noted that Patient # 10 had had at least one previous suicide attempt using insulin (helps control BS levels, can be dangerous in high doses).

3. Review of Patient # 10's CAH medical record revealed:

a. On 3/3/23 at 4:11 PM, RN D documented Patient # 10 presented to the ED by ambulance with complaints of cognitive (mental activity) impairment, depression (mental illness that negatively affects how a person feels), and anxiety (feeling fear, dread, and uneasiness) due to a recent loss of their home health aide service, and the death of Patient # 10's son. Patient # 10's BP was noted as 168/124 (high).

b. On 3/3/23 at 4:31 PM, Patient # 10's BP was 168/124 (high).

c. On 3/3/23 at 4:45 PM, Patient # 10's BP was 192/77 (high).

d. On 3/3/23 at 4:50 PM, DO H noted Patient # 10 was having recent memory loss, had not been taking all of their medication, and had come to the ED because they were severely depressed and wanted help. DO H also noted the clinic report of Patient # 10's past suicide attempt using their insulin. Patient # 10 now denied active suicidal thoughts or a plan to commit suicide. DO H failed to acknowledge that while in the clinic Patient # 10 said they would kill themselves if sent home.

e. On 3/3/23 at 5:01 PM, Patient # 10's BP was 208/104 (high).

f. On 3/3/23 at 5:34 PM, Patient # 10's BP was 223/141 (high).

g. On 3/3/23 at 5:36 PM, Patient # 10's BP was 203/100 (high).

h. On 3/3/23 at 6:42 PM, RN D documented the initial Columbia- Suicide Severity Rating Scale (C-SSRS) assessment . Patient # 10 answered no to all the questions (indicating Patient # 10 had no suicidal thoughts or ideas).

i. On 3/3/23 at 7:00 PM, DO B assumed care of Patient # 10.

j. On 3/3/23 at 8:04 PM, Licensed Master Social Worker (LMSW) M completed a mental health evaluation via tele-health (video assessment using an I-pad) and noted Patient # 10 was living alone, their son had recently died, and they hadn't been able to grieve. Patient # 10 reported their depression as "99" (using a 0-10 scale) and their anxiety as being "pretty high." Patient # 10 admitted to an attempted suicide "a few months ago," but denied any current thoughts of self-harm. LMSW M diagnosed Patient # 10 with major depressive disorder and recommended discharge home with outpatient therapy and monitoring.

k. On 3/3/23 at 8:10 PM, RN G completed a second C-SSRS assessment and an additional suicide risk assessment." Again Patient # 10 answered no to all the suicide questions, denied having a suicide plan, and their suicide risk was documented as "low".

l. On 3/3/23 at 8:12 PM, Patient # 10's BP was 214/89 (high).

m. On 3/3/23 at 8:14 PM, Patient # 10's BP was 202/74 (high).

n. On 3/3/23 at 8:30 PM, DO B addressed Patient # 10 having elevated BP's during their ED visit and ordered them to receive one dose of Metoprolol (a medication used to treat high BP) 50 milligrams (mg).

o. On 3/3/23 at 8:35 PM, RN G administered one dose of Metoprolol 50 mg to Patient # 10.

p. On 3/3/23 at 9:53 PM, Patient # 10's BP was 180/70 (high).

q. On 3/3/23 at 10:00 PM, DO B noted Patient # 10's BP had improved, and they were okay to be discharged home with instructions to continue their previously prescribed BP medication and follow up with their primary care provider in three day for their BP to be checked.

r. On 3/3/23 at 10:50 PM, Patient # 10 was discharged home with instructions for intensive outpatient therapy and monitoring for the next five days. The CAH failed to assure Patient # 10's BP was stabilized prior to discharging them home, and failed to address that Patient #10 lived alone, had a recent loss of their home health care, and a history of not taking their prescribed medication.

s. On 3/8/23 at 10:25 AM (approximately 5 days after the initial ED visit), EMS was again sent to Patient # 10's home for complaints that they "felt funny" and "didn't think [Patient # 10's] head felt right." BP was noted by EMS as 230/95 (high). BP was check by EMS during transport at 10:43 AM, which was 154/96 (high), and again at 10:55 AM, which was 159/86 (high).

t. On 3/8/23 at 10:59 AM, Patient # 10 again presented to the ED by ambulance for complaints of "not feeling well" and feeling that there was something "wrong with [Patient # 10's] head." Patient # 10 had not followed through with intensive outpatient therapy or followed up with their primary care provider, and was again verbalizing thoughts of using their insulin to overdose and harm themselves. DO J medically cleared Patient # 10 for another mental health evaluation.

u. On 3/8/23 at 11:00 AM, RN K triaged Patient # 10, completed a C-SSRS assessment, and Patient # 10 answered "yes" to all the questions (indicating a high risk for suicidal behavior). Patient # 10's BP was noted as 212/90.

v. On 3/8/23 at 2:38 PM, ARNP O did a mental health evaluation via tele-health and determined Patient # 10 would benefit from inpatient psychiatric care and recommended admission to a behavioral health unit.

w. On 3/8/23 at 3:46 PM, DO J ordered Patient #10 to receive one dose of Labetalol (a medication used to treat high blood pressure) 200 mg by mouth.

x. On 3/9/23 at 9:00 AM, an order was placed for Patient # 10 to received Labetalol 200 mg by mount two times daily. Patient # 10 had high BP throughout their ED visit, and received different intravenous and oral medications to treat their high BP.

y. On 3/10/23 at 4:46 PM, Patient # 10 was admitted to the CAH, and on 3/15/23 at 8:22 AM, Patient #10 was transferred to Hospital B's inpatient Behavioral Health Unit.

4. During an interview on 4/26/23 at 2:45 PM, Clinic RN N recalled seeing Patient # 10 in the clinic on 3/3/23. Patient # 10 indicated that they needed someone to take care of them and they would stay at the clinic until someone could help them. Patient # 10 verbalized a plan to kill themselves by taking too much of their medication, not taking their medication, or by throwing themselves out of their wheelchair if they were sent home, or anywhere else other than the hospital. RN N called for ambulance to take Patient # 10 to the CAH ED.

5. During an interview on 4/19/23 at 12:30 PM, Patient # 10's primary care provider, Physician Assistant (PA) I reported they did not see Patient # 10 in clinic on 3/3/23, but knew they had a long history of mental health issues, such as depression, anxiety, and bipolar (mental health condition that causes extreme mood swings). PA I reported the clinic staff took it very seriously when Patient #10 reported they were going to overdose on insulin because Patient # 10 had had a suicide attempt 2 years ago. PA I also reported it is rare that Patient # 10 would follow through with their behavioral health appointments.

6. During an interview on 5/11/23 at 8:45 AM, Paramedic Y, recalled transporting Patient # 10 on 3/3/23 to the ED. Contrary to the the clinic report, Patient #10 denied suicidal thoughts or saying anything like that while being transported to the CAH.

7. During an interview on 5/10/23 at 11:00 AM, RN D recalled triaging Patient # 10 on 3/3/23, and completing a C-SSRS assessment. Patient # 10 denied thoughts of killing themselves or having a plan for self-harm during the triage assessment, or while RN D cared for Patient # 10.

8. During an interview on 4/20/23 at 12:30 PM, DO H reported Patient # 10 was mentally intact and able to answer questions appropriately when DO H examined them in the ED on 3/3/23. DO H did not find any medical reason for Patient # 10's symptoms and referred them for a mental health evaluation that concluded that Patient # 10 did not have any active suicidal thoughts or plan to commit suicide. DO H was aware that Patient # 10 did have a history of depression and an attempted insulin overdose, but explained that they use psychiatric telehealth (health-related electronic service) to evaluate patients with mental health concerns to see if they meet the criteria for inpatient psychiatric care, and then they decide together the best treatment plan for the patient. DO H reported that Patient # 10 did not have any active suicidal thoughts or plan during their assessment or anytime while they were in the ED.

9. During an interview on 4/19/23 at 1:00 PM, DO B recalled Patient # 10 from their 3/3/23 ED visit, recalled they had been evaluated by psychiatric telehealth, who felt it was appropriate to discharge Patient # 10 home with outpatient services.

10. During a follow up interview on 4/27/23 at 11:45 AM, DO B did not recall specifically talking to Patient # 10 about having suicidal thoughts prior to discharging them home, but reiterated that they knew Patient #10 had been evaluated by telehealth and weren't having any suicidal ideation.

11. During an interview on 5/10/23 at 11:47 AM, RN G recalled care for Patient # 10 on 3/3/23. RN G reported Patient # 10 did not verbalize any thoughts of suicide or any plans for self-harm.

12. During an interview on 4/19/23 at 9:30 AM, DO J recalled examining Patient # 10 when they returned to the ED on 3/8/23 (five days after their initial visit on 3/3/23). Patient # 10 verbalized they had previously tried to overdose on insulin in an attempt to harm themselves. Patient # 10 was now verbalizing thoughts of self-harm, so DO J felt it was unsafe for Patient # 10 to be discharged. Patient #10 was admitted to the CAH for their safety until an appropriate behavioral health bed became available on 3/15/23.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #10) with all available and appropriate stabilizing treatment after presenting to the Emergency Department (ED) seeking medical care. Failure to provide all available and appropriate stabilizing treatment at the CAH's ED resulted in Patient #10 returning to the CAH's ED a second time with similar symptoms that required transfer to another hospital for inpatient care. The CAH's administrative staff identified an average of 832 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient # 10's clinic medical record revealed:

a. On 3/3/23 at 3:28 PM, Patient # 10 presented to the clinic with concerns of low blood sugar (BS). Their BS was high at 267 (normal range is 80-100 before eating) and blood pressure (BP) (the pressure of the blood in the circulatory system; normal range 120/80) was 146/86 (high). Patient # 10 reported to RN N that they would kill themselves if they were sent home. RN N noted that Patient # 10 had at least one previous suicide attempt using insulin (helps control BS levels, can be dangerous in high doses).

2. Review of Patient # 10's CAH medical record revealed:

a. On 3/3/23 at 4:11 PM, RN D documented Patient # 10 presented to the ED by ambulance with complaints of cognitive (mental activity) impairment, depression (mental illness that negatively affects how a person feels), and anxiety (feeling fear, dread, and uneasiness) due to a recent loss of their home health aide service, and the death of Patient # 10's son. Patient # 10's BP was noted as 168/124 (high).

b. On 3/3/23 at 4:31 PM, Patient # 10's BP was 168/124 (high).

c. On 3/3/23 at 4:45 PM, Patient # 10's BP was 192/77 (high).

d. On 3/3/23 at 4:50 PM, DO H noted Patient # 10 was having recent memory loss, had not been taking all of their medication, and had come to the ED because they were severely depressed and wanted help. DO H also noted the clinic report of Patient # 10's past suicide attempt using their insulin. Patient # 10 now denied active suicidal thoughts or a plan to commit suicide. DO H failed to acknowledge that while in the clinic Patient # 10 said they would kill themselves if sent home.

e. On 3/3/23 at 5:01 PM, Patient # 10's BP was 208/104 (high).

f. On 3/3/23 at 5:34 PM, Patient # 10's BP was 223/141 (high).

g. On 3/3/23 at 5:36 PM, Patient # 10's BP was 203/100 (high).

h. On 3/3/23 at 6:42 PM, RN D documented the initial Columbia- Suicide Severity Rating Scale (C-SSRS) assessment . Patient # 10 answered no to all the questions (indicating Patient # 10 had no suicidal thoughts or ideas).

i. On 3/3/23 at 7:00 PM, DO B assumed care of Patient # 10.

j. On 3/3/23 at 8:04 PM, Licensed Master Social Worker (LMSW) M completed a mental health evaluation via tele-health (video assessment using an I-pad) and noted Patient # 10 was living alone, their son had recently died, and they hadn't been able to grieve. Patient # 10 reported their depression as "99" (using a 0-10 scale) and their anxiety as being "pretty high." Patient # 10 admitted to an attempted suicide "a few months ago," but denied any current thoughts of self-harm. LMSW M diagnosed Patient # 10 with major depressive disorder and recommended discharge home with outpatient therapy and monitoring.

k. On 3/3/23 at 8:10 PM, RN G completed a second C-SSRS assessment and an additional suicide risk assessment." Again Patient # 10 answered no to all the suicide questions, denied having a suicide plan, and their suicide risk was documented as "low".

l. On 3/3/23 at 8:12 PM, Patient # 10's BP was 214/89 (high).

m. On 3/3/23 at 8:14 PM, Patient # 10's BP was 202/74 (high).

n. On 3/3/23 at 8:30 PM, DO B addressed Patient # 10 having elevated BP's during their ED visit and ordered them to receive one dose of Metoprolol (a medication used to treat high BP) 50 milligrams (mg).

o. On 3/3/23 at 8:35 PM, RN G administered one dose of Metoprolol 50 mg to Patient # 10.

p. On 3/3/23 at 9:53 PM, Patient # 10's BP was 180/70 (high).

q. On 3/3/23 at 10:00 PM, DO B noted Patient # 10's BP had improved, and they were okay to be discharged home with instructions to continue their previously prescribed BP medication and follow up with their primary care provider in three day for their BP to be checked.

r. On 3/3/23 at 10:50 PM, Patient # 10 was discharged home with instructions for intensive outpatient therapy and monitoring for the next five days. The CAH failed to assure Patient # 10's BP was stabilized prior to discharging them home, and failed to address that Patient #10 lived alone, had a recent loss of their home health care, and a history of not taking their prescribed medication.

s. On 3/8/23 at 10:25 AM (approximately 5 days after the initial ED visit), EMS was again sent to Patient # 10's home for complaints that they "felt funny" and "didn't think [Patient # 10's] head felt right." BP was noted by EMS as 230/95 (high). BP was check by EMS during transport at 10:43 AM, which was 154/96 (high), and again at 10:55 AM, which was 159/86 (high).

t. On 3/8/23 at 10:59 AM, Patient # 10 again presented to the ED by ambulance for complaints of "not feeling well" and feeling that there was something "wrong with [Patient # 10's] head." Patient # 10 had not followed through with intensive outpatient therapy or followed up with their primary care provider, and was again verbalizing thoughts of using their insulin to overdose and harm themselves. DO J medically cleared Patient # 10 for another mental health evaluation.

u. On 3/8/23 at 11:00 AM, RN K triaged Patient # 10, completed a C-SSRS assessment, and Patient # 10 answered "yes" to all the questions (indicating a high risk for suicidal behavior). Patient # 10's BP was noted as 212/90 (high).

v. On 3/8/23 at 2:38 PM, ARNP O did a mental health evaluation via tele-health and determined Patient # 10 would benefit from inpatient psychiatric care and recommended admission to a behavioral health unit.

w. On 3/8/23 at 3:46 PM, DO J ordered Patient #10 to receive one dose of Labetalol (a medication used to treat high blood pressure) 200 mg by mouth.

x. On 3/9/23 at 9:00 AM, an order was placed for Patient # 10 to received Labetalol 200 mg by mouth two times daily. Patient # 10 had high BP throughout their ED visit, and received different intravenous and oral medications to treat their high BP.

y. On 3/10/23 at 4:46 PM, Patient # 10 was admitted to the CAH, and on 3/15/23 at 8:22 AM, Patient #10 was transferred to Hospital B's inpatient Behavioral Health Unit.

3. During an interview on 4/26/23 at 2:45 PM, Clinic RN N recalled seeing Patient # 10 in the clinic on 3/3/23. Patient # 10 indicated that they needed someone to take care of them and they would stay at the clinic until someone could help them. Patient # 10 verbalized a plan to kill themselves by taking too much of their medication, not taking their medication, or by throwing themselves out of their wheelchair if they were sent home, or anywhere else other than the hospital. RN N called for ambulance to take Patient # 10 to the CAH ED.

4. During an interview on 4/19/23 at 12:30 PM, Patient # 10's primary care provider, Physician Assistant (PA) I reported they did not see Patient # 10 in clinic on 3/3/23, but knew they had a long history of mental health issues, such as depression, anxiety, and bipolar (mental health condition that causes extreme mood swings). PA I reported the clinic staff took it very seriously when Patient #10 reported they were going to overdose on insulin because Patient # 10 had had a suicide attempt 2 years ago. PA I also reported it is rare that Patient # 10 would follow through with their behavioral health appointments.

5. During an interview on 5/11/23 at 8:45 AM, Paramedic Y, recalled transporting Patient # 10 on 3/3/23 to the ED. Contrary to the the clinic report, Patient #10 denied suicidal thoughts or saying anything like that while being transported to the CAH.

6. During an interview on 5/10/23 at 11:00 AM, RN D recalled triaging Patient # 10 on 3/3/23, and completing a C-SSRS assessment. Patient # 10 denied thoughts of killing themselves or having a plan for self-harm during the triage assessment, or while RN D cared for Patient # 10.

7. During an interview on 4/20/23 at 12:30 PM, DO H reported Patient # 10 was mentally intact and able to answer questions appropriately when DO H examined them in the ED on 3/3/23. DO H did not find any medical reason for Patient # 10's symptoms and referred them for a mental health evaluation that concluded that Patient # 10 did not have any active suicidal thoughts or plan to commit suicide. DO H was aware that Patient # 10 did have a history of depression and an attempted insulin overdose, but explained that they use psychiatric telehealth (health-related electronic service) to evaluate patients with mental health concerns to see if they meet the criteria for inpatient psychiatric care, and then they decide together the best treatment plan for the patient. DO H reported that Patient # 10 did not have any active suicidal thoughts or plan during their assessment or anytime while they were in the ED.

8. During an interview on 4/19/23 at 1:00 PM, DO B recalled Patient # 10 from their 3/3/23 ED visit, recalled they had been evaluated by psychiatric telehealth, who felt it was appropriate to discharge Patient # 10 home with outpatient services.

9. During a follow up interview on 4/27/23 at 11:45 AM, DO B did not recall specifically talking to Patient # 10 about having suicidal thoughts prior to discharging them home, but reiterated that they knew Patient #10 had been evaluated by telehealth and weren't having any suicidal ideation.

10. During an interview on 5/10/23 at 11:47 AM, RN G recalled care for Patient # 10 on 3/3/23. RN G reported Patient # 10 did not verbalize any thoughts of suicide or any plans for self-harm.

11. During an interview on 4/19/23 at 9:30 AM, DO J recalled examining Patient # 10 when they returned to the ED on 3/8/23 (five days after their initial visit on 3/3/23). Patient # 10 verbalized they had previously tried to overdose on insulin in an attempt to harm themselves. Patient # 10 was now verbalizing thoughts of self-harm, so DO J felt it was unsafe for Patient # 10 to be discharged. Patient #10 was admitted to the CAH for their safety until an appropriate behavioral health bed became available on 3/15/23.