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Based on medical record reviews, a review of video surveillance, interviews with staff, and a review of policies and procedures, it was determined that the facility failed to stabilize and treat one out of 20 sampled patients (P) #1 when P#1 arrived at the ED for further evaluation and treatment of mania.

Findings:

Cross refer to A-2407 as it relates to the facility's failure to stabilize and treat P#1.

Based on medical record reviews, a review of video surveillance, interviews with staff, and a review of policies and procedures, it was determined that the facility failed to stabilize and treat one out of 20 sampled patients (P) #1 when P#1 arrived to the Emergency Department (ED) for further evaluation and treatment of mania.

Findings:

A review of a medical record revealed that P#1 was a 27-year-old who arrived at Facility #1's emergency department (ED) via emergency medical services (EMS) on 6/18/22 at 5:22 a.m. for further evaluation of mania (periods of abnormally elevated, extreme changes in moods or emotions). P#1 had a past medical history of bipolar disorder (extreme mood swings) and Human Immunodeficiency Virus (HIV). A review of the ED course revealed initial symptoms upon presentation were concerning for psychosis (condition of the mind where there is loss of contact with reality). P#1 symptoms improved substantially after receiving a dose of Geodon (an antipsychotic medication). A review of an 'ED Physician Report' revealed that Hospital Medicine did not want to admit P#1 because of P#1's behavior on a previous admission on 6/9/22.

P#1 had become briefly agitated and combative. P#1 chased his sitter around the nursing unit and attacked her. Security became involved, and P#1 had to be restrained. ED physician (MD) JJ ordered 4-point (device used on both wrists and both ankles) restraints (a device that limits a person's movement) for P#1 due to his violent behavior upon admission to the ED. Further review revealed that P#1 was to be administered a re-dose of Geodon while in the ED, and if P#1 continued to behave appropriately, P#1 would be discharged with a relative. P#1 was to follow up with outpatient psychiatry. Information was to be provided for three facilities that had inpatient psychiatric options. Facility #1 did not have inpatient psychiatry nor telepsychiatry (use of video conferencing in psychiatry) available on the weekends. P#1 denied homicidal or suicidal ideations. P#1 was discharged from the ED on 6/18/22 at 2:07 p.m.

A review of Facility #1's ED video surveillance (VS), dated 6/18/22, was conducted with Support Service Manager (SSM) OO in the security office. The video surveillance revealed the following:

* 5:17 a.m. American Medical Response (AMR) EMS arrived at the facility ambulance bay with P#1.
* 5:18 a.m. AMR driver stepped out of the driver's side of the ambulance, walked towards the rear of the ambulance, and opened the doors. AMR driver pulled the stretcher from the back of the ambulance and took P#1 to the ambulance entrance door of the ED.
* 5:19 a.m. AMR driver rang the security doorbell, and an employee (no visual inside ED from the ambulance bay) opened the door. The AMR driver brought P#1 in through the automatic entrance door. A continued review revealed that P#1 was restrained and strapped to the stretcher with straps across P#1's legs and around P#1's upper arms.
* 1:54 p.m., P#1 and a female were escorted by two security officers through the hospital hallway and out of the exit doors to an awaiting car outside the facility.

A review of P#1's medical record from Facility #2 revealed that P#1 arrived at the ED on 6/18/22 at 4:56 p.m. by a personal vehicle. An ED nursing note dated 6/18/22 at 5:40 p.m. documented a behavioral health assessment was completed. P#1 stated he wished to kill his family by any means necessary. When asked how he would commit the action, P#1 responded however he could.

An ED nursing note dated 6/18/22 at 6:25 p.m. revealed staff at Facility #2 reviewed the discharge paperwork from Facility #1. The nurse at Facility #2 spoke with the relative of P#1. The relative revealed to Facility #2 that P#1 was given a list of locations where P#1 could be seen and treated due to the lack of resources for behavioral health on the weekends.

An ED Provider Note dated 6/18/22 at 7:39 p.m. by a medical doctor at Facility #2 documented that P#1 was seen at Facility #1 for a mental health evaluation. P#1 was discharged from Facility #1 after receiving two (2) intramuscular (injections given directly into the muscle) of Geodon (an antipsychotic medication). After being discharged from Facility #1, P#1 relative noted P#1 was not stable and bought P#1 to Facility #2 for further evaluation. The evaluation further documented that upon arrival at Facility #2, P#1 was mumbling in his room and appeared to be reacting to internal stimuli. P#1 required redirection many times when asked questions. A 1013 (emergency psychiatric transfer document) was completed due to P#1 responding to internal stimuli and a homicidal statement made by P#1 to the Registered Nurse during the assessment.
P#1 was discharged from Facility #2 to a psychiatric receiving facility on 6/20/22 at 4:53 p.m. to continue receiving treatment.

A review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening, Treatment and Related Issues," no policy number, effective 10/20/16, revealed any individual who presented to the ED or Labor & Delivery and requested care should be offered an appropriate Medical Screening Examination (MSE) to determine if the individual had an Emergency Medical Condition. If an Emergency Medical Condition (MSC) exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the Hospital Policy on Transfers.

A telephone interview was conducted with Registered Nurse (RN) NN on 7/18/22 at 6:15 p.m. RN NN stated that she was P#1's nurse during P#1's ED admission to Facility #2 on 6/18/22. She continued to say that P#1 was fully psychotic, and P#1's relative stated that P#1 had threatened to kill her. She further said that P#1 was very agitated, delusional, and pacing the floor calling himself Beyonce. RN NN stated that P#1's relative explained to her that P#1 was at Facility #1 earlier in the day and was informed that due to a lack of resources, P#1 could not be treated at Facility #1. RN NN explained that she reviewed the documents given to P#1's relative, which included a note stating, "due to lack of resources," P#1 could not be treated at the facility. P#1's relative was also given a list of hospitals in the area to which P#1's relative could take P#1, including Facility #2.

A telephone interview was conducted with ED Hospitalist (MD) II on 7/19/22 at 3:50 p.m. MD II stated he recalled P#1 from his previous admission on 6/9/22 and his recent ED visit on 6/18/22. MD II recalled that he stabilized P#1 when P#1 was admitted through the ED on 6/9/22. P#1 was given a regimen that worked for P#1, but when P#1 returned home, P#1 was non-compliant. MD II continued to say that on 6/18/22, P#1 presented to the ED psychotic. P#1 was first seen by his mid-level Physician Assistant (PA) KK, who assessed and treated P#1. MD II said that P#1's visit to the ED on 6/18/22 was not a presentation of a new problem. It was a plan of care that had been established, and P#1 was non-compliant. MD II stated he re-stabilized P#1 and got P#1 back on the established care plan. MD II said P#1 was appropriate for discharge.

A telephone interview was conducted with PA KK on 7/19/22 at 4:15 p.m. PA KK stated that P#1 came to the ED at the end of the night shift on 6/18/22, and the overnight doctor, MD JJ, had ordered restraints and some medications in an effort to calm P#1 down. PA KK stated she had administered P#1 intravenous (IV) fluids and consulted with the Hospital Medicine Team (Hospitalists (MD) LL and MD II) to ask if it would be appropriate to admit P#1. She stated that the Hospital Medicine Team did not think P#1 needed to be admitted to the facility. PA KK said MD JJ ordered restraints and Geodon, and these interventions seemed to calm P#1 down substantially. That is when MD II recommended P#1's discharge.

An interview was conducted with RN EE on 7/20/22 at 9:45 a.m. RN HH stated she recalled providing care for P#1 on 6/18/22. She continued to say that she communicated with P#1's relative on two occasions, once when P#1 came to the ED and then again when P#1 was discharged from the ED. RN EE said she arrived at Facility #1 for her shift at 7:00 a.m. P#1 was already in 4-point restraints. She continued to say that in reviewing P#1's chart, when he initially arrived at Facility #1, P#1 had some type of internal stimuli (behavioral change) going on, and he needed to be put in restraints due to his violent behavior. RN EE continued to say that she would not go into his room alone. Instead, she would have another nurse or technician with her when P#1 needed to use the urinal, eat or drink.

A telephone interview was conducted with RN FF on 7/20/22 at 9:55 a.m. RN FF stated she recalled P#1 being transported to the ED by EMS stretcher on the morning of 6/18/22 at approximately 5:00 a.m., which was at the end of her shift. She continued to say that when P#1 entered the ED, he was on an EMS stretcher with his legs and arms under restraint. She stated that P#1 was very erratic and was physically out of control with EMS staff and security. She said that he was placed in a room, and then she checked in P#1. RN FF said P#1 was given medication to help calm him down. RN FF could not recall which medication was given. She stated after P#1 received his medication, she handed him off to the nurse arriving on duty. RN FF could not recall the name of the nurse.

A telephone interview was conducted with MD JJ on 7/21/22 at 8:45 a.m. MD JJ stated he recalled P#1 from the ED visit on 6/18/22. MD JJ said that when P#1 arrived at Facility#1 by ambulance, he was combative and violent towards EMS staff and security. He continued to say that due to P#1's violent behavior on admission, he ordered 4-point restraints and Geodon to assist in calming P#1 down. MD JJ continued to say that he was going off shift when P#1 arrived at the ED; this was the only treatment he provided. He continued to say that he did not assess or see P#1 again.

Summary:

Patient #1 required continued psychiatric care, but was refused admission. Patient #1 was discharged from the ED and family had to transport to Facility #2 for stabilization of his emergency medical condition.